• Medical record reviewers are an asset when one is attempting to navigate medical records created by e-charting. LNCs must stay familiar with such systems.
By S. J. Winsor, RN, CCRN, CLNC
© The Medical-Legal News 2007
Love it… Hate it… Tolerate it … e-charting is here to stay. Marketed in the 80s with the promise of paperless charting and time-saving capabilities that would enable nurses to spend more time with their patients (improving patient satisfaction scores), hospitals leapt at the prospect. But as those of us who continue to use e-charting in the clinical setting and who also review the reams of paper contained in medical records know, in reality charting is anything but paperless. Redundancy and duplication continue to plague charting systems. Every time a single entry has to be re-charted in another screen or chart section, there is an opportunity for a mistake. When that record is reviewed under the scrutiny of a records reviewer, such as a legal nurse consultant, the discrepancy becomes a glaring question.
E-charting is beneficial in the capture and tracking of objective data — conditional of the accuracy of any component that has to be manually entered by the practitioner. This type of data includes, but is not limited to: IVs and invasive lines; date, time and site of insertion; location and type of drains and tubes; vital signs, hemodynamics, IABP and ICP; and type and volume of I&O. E-charting also date- and time-stamps each entry made by the practitioner signed on to that station. It will also date- and time-stamp modifications to saved charting. The ability to track user activity of the system has resulted in institutional blocks to internet access and greater compliance with HIPAA.
E-charting often poorly captures subjective aspects of the patient assessment and changes in the patient’s condition. Fortunately most of these areas such as color, amount, consistency, and size have “other” as a choice that provides space for a narrative comment. Unfortunately, the “comment” field has a capacity limit which may not allow for complete documentation. I have found that accurate documentation of wounds and dressings to be one of the most cumbersome and inefficient areas of e-charting. A major hazard of e-charting is that if the practitioner who is signed on to a station leaves that station signed on and unattended, someone else can chart on the open system and it will be attributed to the signed-on user.
The value and short comings of e-charting are best appreciated and understood by the frontline user. In addition to the aforementioned, the operational slowness, frequent inability to go back to previous pages without losing documentation, and the “point and click” nature (increasing the potential of developing carpal tunnel) add to the challenges of e-charting.
With each “innovation” the medical record becomes more of a patchwork to be pieced together by the most knowledgeable user or practitioner. •
Susan J. Winsor is a Legal Nurse Consultant in North Chicago, Ill. ; firstname.lastname@example.org.