Your shift starts off with one of your patients crashing, your new admission arriving, and the gentleman in room 204 falling and hurting himself. Immediately you feel the pressure of all you have to accomplish. You may be thinking, “How will I get this all charted in a timely manner and still handle my med pass on time?” The healthcare industry has recognized this plight and has made strides to help nurses more efficiently handle their daily tasks, including charting.
While the introduction of electronic health records was intended to make life easier for nurses, doctors and other healthcare staff, that isn’t always the case. In fact, 92 percent of nurses who participated in one survey reported some dissatisfaction with electronic health records (EHR) or electronic medical records (EMR). Luckily, there are a few things you can do to make electronic charting easier.
1. Keep a keen eye for mistakes
Making mistakes is easy if you have several patient records open at the same time. Although it seems obvious, double-checking the patient name at the top of the screen may save you considerable time. If you accidentally enter information in another patient’s chart, you have to delete every incorrect entry and include a note explaining why you made the deletions.
2. Chart in real time
It may be tempting to do when you are very busy, but if you postpone charting until the end of the day, it may actually take more time than if you entered the information immediately after working with a patient. By the end of the day, those little details aren’t so fresh in your mind, and you will have to take time to verify information like: new orders, patient education, responses to pain interventions, etc. Real-time charting also ensures that other health care providers can access up-to-date information on patients.
3. Take advantage of additional training
Some hospitals have complex electronic health record systems that can make some aspects of documentation feel confusing. If you find navigating your EMR difficult, ask for additional training or seek out colleagues who are well versed in the technology.
4. Speak up
Electronic charting is still in its infancy, and in many hospitals, there’s room for improvement. If you and your co-workers are feeling frustrated, speak up. Your input as an end user is valuable! Help identify problems with the system that waste time better spent on patient care. Think about things that could make it easier to work with the system. For example, if you must page through multiple screens that don’t apply to your unit, discuss this with your nursing informatics representative to let them know about how it impacts your workflow.
When an EHR system performs well, nurses may actually have more time to devote to patient-centered care. Learn more about patient-centered care in our free guide, How Nurses Can Increase Patient Satisfaction Through Patient-Centered Care.