Electronic Documentation
Our organization uses an electronic medical record (eMAR) for documentation, and we chart by exception. If there is no change in the client’s status, what would be the appropriate way to document in each field, keeping with the charting by exception format?
CNO does not have guidelines for the charting by exception format. However, all nurses are expected to follow the accountabilities in the Documentation practice standard. This includes ensuring that documentation is a complete record of nursing care provided and reflects all aspects of the nursing process.
As practice settings are diverse, employers can develop specific policies regarding documentation practices that meet the needs of their clients and setting requirements.
Nurses and employers are partners in client safety. Nurses are encouraged to advocate for clear documentation policies and processes that align with the standards of practice.
I work in a family health team, and I frequently receive orders via text messages and emails. What is my accountability when receiving and documenting these orders?
Organizations use various methods to receive information related to client care, including orders. Nurses must accept orders that are clear, complete, and appropriate as noted in the Medication practice standard. When a nurse receives an order that is unclear, incomplete, or inappropriate, the nurse must not implement the order and follow up with the prescriber in a timely manner.
When documenting orders, nurses must ensure relevant client care information is captured in a permanent record and that their documentation of client care is accurate, timely and complete.
When receiving information via text and email, nurses must also ensure privacy and confidentiality of personal health information. This includes ensuring that communication received is secure and considering whether there may be any potential risks for disclosing personal health information.
As partners in patient safety, CNO strongly encourages employers to have policies in place that clearly outline the accountabilities of nurses to receive orders and communications electronically. Nurses are encouraged to work with the broader health care team to develop policies on how orders are received and documented that are in alignment with CNO standards of practice.
My facility just introduced an electronic order entry system. The system alerts me when an order is received for my client. How can I be sure that it was the physician who entered the order and not someone else using the physician’s electronic signature?
The information technology professionals who installed and support your new system should be able to inform you about the security of the system and confirm whether only the authorized user has access to his/her electronic signature.
If you are aware that an electronic signature is being used without authorization, report this to the contact person in your practice setting.
Health care professionals can protect the integrity of their electronic signatures by:
- maintaining the confidentiality of passwords or other access information;
- changing their password as per facility policy or more frequently if security is at risk;
- using passwords that are not easily deciphered;
- logging off when not using the system or when leaving the terminal;
- ensuring that the keyboard and monitor are placed to ensure maximum privacy and confidentiality; and
- advocating for appropriate education and technical support.
