Documentation errors


One of the things I have found with the electronic documentation that my hospital is doing is the proclivity for ongoing documentation errors. Most of the daily or BID assessments are simply template forward with a check box placed by the assessing nurse. I have found errors as simple as documentation of the wrong extremity for IV placement that went on for several shifts before it was caught. With paper documentation each area had to be filled out originally and required thought, I can foresee legal issues for the nurse and hospital with this system. I know all systems have liabilities but in the quest to make it user friendly, I think it has left us vulnerable.


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