This article provided by: Travel Nurse Across America
Cerner, Meditech, or EPIC. Every travel nurse has their favorite. And their favorite EMR to gripe about. Whatever EMR you prefer, they all serve the same purpose: improving the speed and accuracy of patient care. However, legal proceedings often utilize medical charting to determine the merits of a lawsuit. While a good travel nurse agency will have protections in place for their travel nurses, there are things you can do to minimize your risk when charting.
Get Comfortable With Pre-Populated Boxes
When using an EMR, you want to try to and use the options given as much as possible. Doing this will eliminate double documenting. While you may be tempted to utilize the narrative box as a place to summarize, if a pre-populated box covers it, you’re double documenting. Legally, there is less wiggle room if you use the given options as there is no room for assumptions. Plus, it allows for better data collection. Accuracy is the name of the game as this information stays with the patient for a long time and can impact things in their future 10-20 years down the road, whether it’s with their insurance or a lawsuit.
Document in Real-Time
Every nurse has heard the adage, “if it wasn’t charted, it wasn’t done,” and that holds. Most facilities push for point-of-care charting, and while it can be a hassle, it can also save you from trouble down the road. Batching your documentation can seem like a good idea, but it can actually take longer. But the real draw of point-of-care documentation? Many EMRs use predictability models in their programming, which can alert nurses and other clinicians, like a rapid-response team, if a patient is expected to decline or if it notes declining stats. That can save lives.
Charting Tips When Perfect Charting Isn’t an Option
While we want to encourage you never to be too busy for accurate charting, the reality can be quite different. Whether you’re floated to a new unit and trying just to keep your head above water, or all of your patients need everything all at once, point-of-care charting might move to the back burner.
Here’s what you can do to continue to protect yourself:
- Don’t wait until the end of the day. Catch up, take a breath, and get to charting. If you can’t designate time on the computer, jot down quick notes throughout the day.
- Stick to the facts. It’s never suggested to include your opinion or to leave comments open-ended or for assumptions to be made.
- Chart what you know. Think preventions utilized, resources used, and advocacy provided.
Look for an Agency That Takes Risk Management Seriously
Healthcare can be prime for lawsuits, and while we don’t want to scare you, it’s important to take seriously. And a good travel nursing agency should take it seriously. Your agency should have clinicians on staff who can provide career guidance. Your agency should have legal staff who can provide guidance to agency practices, contract protection, and risk management. Ask your agency how they protect their nurses. Are they taking any proactive measures to help you? It’s an unfortunate side of healthcare, but it happens.
We hope you found these tips for charting helpful. If you would like more tips on charting check out: Charting Made Easy: The SOAPI Note
