Electronic Health Records

Nursing BC, Dec 2004 by Herman, Carina

Many health care organizations today are in the process of transitioning to some form of electronic health record. This transition often occurs in stages rather than moving from a completely paper health record to a completely electronic health record. While the principles of documentation are the same for electronic and paper records, the processes involved need to change when moving to an electronic health record.

An electronic health record can improve client care, decrease errors and decrease workload. However, simply turning an existing paper record into an electronic record will not result in these outcomes. The way information is gathered, recorded, accessed and used needs to be analyzed in order to develop processes that are effective and meaningful for electronic documentation. Each agency should have policies in place that outline how electronic documentation is to be recorded and used, and how and by whom it can be accessed.

Registered nurses and other health care professionals have important roles in the selection or development of an electronic health record. Their involvement can lead to an electronic system that supports best practice rather than a system that dictates how practice should occur.

RNABC nursing practice consultants frequently receive questions and comments from registered nurses who are beginning to delve into the world of electronic documentation. Here are a few of them.

Q The unit on which I work is in he process of changing to an electronic health record, but until we are sure it is working right we are using both paper and electronic records. Is this okay?

A While there is nothing that says you cannot do this, it is not recommended to use both paper and electronic records. As you have probably noticed, charting the same thing twice results in a greater workload. Moreover, charting in two different formats has the potential for creating communication errors. For example, if you chart on the paper record, then get busy and forget to chart on the electronic record or don't chart in exactly the same way, communication becomes unclear.

Before switching to an electronic system, it is helpful to practise on a test area of the electronic system to get comfortable with how it works and to identify and address any systems problems. However, if you are entering actual client information into the electronic record, it is important to have policies that clearly state which is the legal health record - the electronic record or the paper record. This will keep communication clear and decrease the potential for errors from inconsistent documentation on the two charts.

Q Since we can't sign our name to ur electronic documentation, how can those reading it know who charted what?

A An electronic signature can be used to identify the information you enter into the electronic record. An electronic signature may be a unique password, code, personal identification number, etc. Some systems automatically provide an electronic signature through your login and password. In other systems, you identify yourself through your initials or name on the actual electronic record. Either way, the electronic signature links the document to the writer.

Q Logging into the computer several times a day is a pain. Can't I just log into it at the beginning of my shift and leave it open?

A As registered nurses, we have an obligation to protect the confidentiality of our clients. Staying logged into the computer when you are not using it leaves the system open and can breech confidentiality as others can view or access client information from the computer. Depending on where your computer is located, staff, visitors, families or others may be able to view or access client information. Leaving the record open allows for the potential of others to enter information that will be recorded under your electronic signature. You should log off or lock the computer when you are leaving it.

Q I am concerned that someone ill go into the client record and change the information I have entered. How can I prevent that from happening?

A All entries need to be password protected so that no one can make changes to your entries. The security of the electronic system is crucial to maintaining confidentiality and preventing errors. Users of the system should never give out their password and should always log off when leaving the computer. If you must write your password down in order to remember it, be sure to store it in a secure place where others cannot find it. Organizations need to determine who within the organization has access to what portion of the computer record. Passwords are then designed to allow individuals to access only those sections of the electronic system that are necessary for them to complete their work.

Q I realize that I charted someing incorrectly on the electronic chart, can I go back and delete it and insert the correct information?

A No, just as you would not erase an incorrect entry in the paper record, you would not delete an incorrect entry from the electronic record. Your agency needs to have policies in place that outline how incorrect entries and/or late entries are to be handled.