By: Stacey Holman, Director of Clinical Products
Electronic documentation has many benefits, such as legibility, accessibility, improved coordination among clinicians, efficiency and portability of information to other systems. Facilities need to consider how the documentation system is set up, the policies and procedures for documentation and the training of clinicians. Documentation systems allow information to be copied forward or populated automatically from the previous documentation. This may help ease the burden of documentation for clinicians, but clinicians must be diligent in validating the data. With increasing patient acuity and nursing shortages, are clinicians always able to catch when information has changed and update the documentation accordingly?
Some systems allow facilities to determine what information can be copied forward based on a time frame. Others allow users to only copy “their documentation” forward. Some systems may bring forward historical information, so the information is always available. For example, if a patient had a tonsillectomy in 1982, this information does not change. However, if the person previously had “No Known Allergies” documented on the last visit but has since had an adverse reaction to Penicillin, the clinician would need to change “No Known Allergies” to “Penicillin Allergy.”
A common argument against copying documentation forward is the risk of clinicians failing to validate the copied information. For this reason, some facilities have policies that prohibit the practice while others may allow only specific information to be copied, such as surgical history. Removing/not allowing copy forward may cause some clinician dissatisfaction. For example, clinicians may want the IV site documentation to be pulled forward. However, this can be a common cause for inaccurate documentation. Here’s an example: The IV was documented as placed in the left hand for four days, but the site infiltrated on day two, and the IV has been in the right hand for the past two days.
The goal is accurate, timely documentation, and with meaningful use, healthcare providers need to share information between systems, making accurate documentation imperative. Is allowing copy forward a time-saver for your clinicians, or does it enable “bad documentation” by some? These are things to consider when writing policies and defining how your EHR system is going to work best for your clinicians.
Frank Newlands, M.D.