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When it comes to nursing documentation, knowing a way to document a patient accurately will virtually mean life or death. The majority of the foremost common medical documentation errors may be the foremost disastrous. Plus, improper documentation will open up an employer to liability and malpractice lawsuits.
So how will we ensure to avoid the foremost nursing documentation errors, to confirm patients receive acceptably and, presumably, life-saving care? One way is to ensure that our nursing students have the proper coaching on using School Nurse EHR Software, also known as electronic health records (EHRs), while still in class.
Here are a number of the highest nine forms of medical documentation errors:
Sloppy or undecipherable handwriting
Failure to date, time, and sign a medical entry
Lack of documentation for omitted medications and treatments
Incomplete or missing documentation
Adding entries shortly
Documenting subjective data
Not questioning incomprehensible orders
Using the incorrect abbreviations
Entering data into the incorrect chart
How Does an EHR Reduce Nursing Documentation Errors?
Proper and accurate documentation is essential to avoid nursing documentation errors and avoid patient deaths or increased liability for the caregiving facility, physician, or nurse. This is where EMRs come in and where nursing students' practical EMR training can play a vital role.
A good and effective documentation should be:
Accurate
Factual
Complete
Timely
Organized
Compliant with health laws and facility standards
Academic EMRs profit nursing students in preventing medical documentation errors before stepping into real-world practice. Students have shared that educational EHRs improved their charting performance, critical thinking skills, and preparedness for practice after graduation. Instructors profit too and say that the exploitation of an educational School Nurse Health System allows them to produce immediate feedback to students and help students develop clinical reasoning skills.