NEW YORK NURSE: September 2011
Q.: My facility is switching to an electronic documentation system and it has raised many concerns. What are nurses’ responsibilities for using these systems?
A.: Electronic documentation has become an integral part of patient care and nursing. In 2001, the Institute of Medicine recommended the use of informatics to improve quality of care. Recently, the American Recovery and Reinvestment Act of 2009 provides financial incentives for hospitals that adopt electronic documentation systems that clearly demonstrate meaningful use by the year 2014 (U. S. Department of Health and Human Services, 2011). Documentation brings with it nursing responsibilities regardless of whether it is an electronic or paper process.
Patient care that is accurately reflected within a medical record is an expectation grounded in law, ethics, standards, as well as policy and procedures. Federal and state regulations provide the structure for reimbursement and other requirements such as the maintenance of patient privacy. Documentation that indicates continuity of care, including significant observations, interventions and outcomes is also required.
Standards to guide documentation come from a variety of nursing associations. The American Nurses Association recently updated their documentation principles to guide what, when, and how nurses document (ANA, 2011). Specialty nursing associations also offer standards specific to practice areas to assist nurses in how to reflect quality patient care in documentation.
Adding informatics to nursing education curriculum and ensuring opportunities for continuing education regarding accountability, potential liability and ongoing responsibilities are essential (Quality and Safety Education for Nurses, 2011; Technology Informatics Guiding Educational Reform, 2009). Nurses must remain current with today’s technology and be familiar with its abilities and limitations. Technology can increase competency and continuity of care while decreasing potential professional liability (Nurses Service Organization, 2011).
Nurses have a duty to maintain competency in all areas of practice and this includes the responsibility for accurate documentation. Employers are also responsible for ensuring nurses have access to education and training specific to their electronic documentation systems, as well as related policies and procedures. If you are represented for collective bargaining, speak to your nurse representative about questions or concerns related to electronic documentation.
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Springs, MD: Nursesbooks.org
American Nurses Association. (2011). ANA principles for documentation. Retrieved from www.nursingworld.org
Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academy Press.
Nurses Service Organization. (2011). Keeping up with technology: Your risks and responsibilities. Retrieved from http://www.nso.com/nursing-resources/article/250.jsp Quality and Safety Education for Nurses. (2011). Informatics. Retrieved from www.qsen.org
Technology Informatics Guiding Educational Reform (TIGER). (2009) TIGER Informatics Competencies Collaborative (TICC) final report. Retrieved from http://tigercompetencies.pbworks.com/f/TICC_Final.pdf
United States Department of Health and Human Services. (2011). Electronic health records and meaningful use. Retrieved from: http://healthit.hhs.gov/portal/server.pt?
This is a sample of the questions NYSNA’s experts answer each day. The advice given is specific for the situation described and may not be applicable generally. If you have questions about your own work setting, it is recommended that you contact your NYSNA nursing representative or the Education, Practice, and Research Program, 11 Cornell Road, Latham, New York 12110-1499 or call 800-724-NYRN, ext. 282.