Documentation has been a growing problem in the healthcare industry especially short-staffed nursing homes. In an article from Medscape, issues with charting are looked at and explored for potential problems. A nurse posed a question about charting. She detailed how the electronic charting system at her hospital was so cumbersome that many nurses had to stay over their shifts, which necessitates overtime, or they were clocking out and entering notes on their own time so that the charts would be up to date. The problem, she said, is that by the time the notes are entered, the patient’s condition could have drastically changed. Since the system records the time of the notes, this could lead to issues of charting integrity and in some cases, HIPAA violations.
The documentation standard is for charts to be updated within an hour of the assessment or treatment, unless more frequent updates are required, such as for a patient who requires more frequent nurse assessments. Untimely documentation leads to issues of the credibility of those notes. If a patient dies at 8:00 and the nurse enters her notes that he is healthy and well at 8:15, there’s obviously an issue of integrity.
Electronic charting systems, like all newly implemented computer systems, will require some work to become familiar with the program. Maybe the nurses are going through a learning period, and as they work with the program it will be easier to use and easier to timely enter chart notes. If the system is too difficult to work with, nurses are probably not the only ones having problems. If doctors and nurses are both frustrated with the system, then a meeting should be set up with the administration. In either case the situation is going to require time. For right now, it seems inevitable that charting integrity will continue to be a source of concern for many hospitals.