By Nelita Zytkowski, DNP, MS, BSN, NEA-BC, RN-BC
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Electronic documentation has improved our world in so many ways. We have instant access to patient information through faster, channeled and more precise ways. But what happens when our real-time, instant access to information is shut off? While technology is critical to nurses, Cleveland Clinic encourages caregivers to keep a few things in mind when electronic medical records “take a day off.”
The system is down. Now what?
System downtimes occur for many reasons. Sometimes you know in advance that routine maintenance or enhancement installations will be performed. Occasionally, unscheduled system outages occur, revealing just how dependent we have become on automated solutions and technology.
When our electronic medical record system goes down many caregivers have to retrain themselves on how to document, retrieve and share information that is manually collected. This paradigm shift often feels like someone has tied your dominant hand behind your back and asked you to finish your work with the opposite hand: The task is technically possible, but it’s slow, labor intensive and, at times, uncomfortable. Additionally, most new nurses have only known electronic charting, so there is no such thing as “going back to paper.”
Tips for paper documentation during EMR downtimes
There are a few key tips that all clinicians should keep in mind when documenting on paper records during system downtimes.
- Write legibly. Cursive writing is the standard for narrative documentation and orders on paper forms. Always use a blue or black ink pen.
- Sign all documentation. In order to track back the care of the patient in the legal medical record, it is essential that you sign your name to all documentation entries. A signature key form allows clinicians to print their initials next to their documentation and sign their names next to those initials so anyone looking in the record can track back initialed documentation to the caregiver who documented it.
- Date and time everything. This helps accurately record when things were noted or completed and also eases transcription back into the electronic record as needed. Having an accurate date and time for when care occurred helps with audits of paper records and historical reviews of documentation that occurs when systems are down. This information is also helpful when capturing a change in patient condition and the events and documentation associated with those occurrences.
- Use official forms appropriately. If you’ve never used a specific downtime form before, make sure you familiarize yourself with the intended purpose of the form and how it should be correctly filled in. Use forms only for their intended purpose. For example, if you have a form to capture vital signs, do not use a blank form to document this information. Do not write extra information in the margins or at the end of a specific form. Misuse or lack of using official forms leads to lost, misfiled and miscommunicated information.
- Use the appropriate error correction notation. Never scratch out, erase or cover up any part of a written record. To correct an error in documentation place a single line strikethrough over the error and initial the statement. Then add the correct information to the record.
No one likes when the EMR system takes a day off, but the unfortunate reality is that electronic systems sometimes experience downtimes. While most planned downtimes happen during off hours, each caregiver must be ready to respond and continue with care of patients at any time. Be prepared by brushing up on your paper documentation skills.
Nelita Zytkowski, DNP, MS, BSN, NEA-BC, RN-BC, is the Associate Chief Nursing Officer of Nursing Informatics at Cleveland Clinic.