1. Simpson, Kathleen Rice PhD, RNC, FAAN

Article Content

Electronic health records (EHR) are still in their infancy. Perhaps in 10 years or so, they might be mature enough to realize more of their promise. Currently, many aspects remain cumbersome and nonintuitive for the user. Duplicate entries of the same or similar data into separate systems are often required because the systems don't "talk" to each other. It is not uncommon for nurses to have several screens in a patient room reflecting different EHR systems: electronic fetal monitoring (EFM) surveillance, EFM documentation, other nursing documentation, and medication administration. Many nurses report that computer care can supersede nursing care at times (Simpson, Lyndon, Wilson, & Ruhl, 2012). Ergonomics and screen location often force nurses to face the computer instead of looking directly at their patients while they are obtaining information for the history and admission assessment, and ongoing assessments. Most prenatal records are not in a useful place in the EHR as they are scanned in from providers' offices and clinics that use a different EHR from the hospital. Important information is a risk for being lost, overlooked, or transcribed incorrectly into the EHR with this method.


Review of cases in the EHR is a real challenge. The reviewer's view looks nothing like the view of those who originally entered their notes. With so much of the data entered via "clicks" and automatic phrases, it takes significant effort to find content that reflects human thought and critical thinking. Even in progress notes, an area of the record that should contain content with evidence of critical thinking, automatic phrases and carry-the-same-data-forward features obscure the ability to discern what the care provider was thinking, doing, or planning for the patient. The "copy-forward" method perpetuates errors and missing data from earlier entries and discourages the careful thought process necessary to add new information. Copy-paste and copy-forward features are sometimes used to populate all of the required clinical fields in the electronic labor flow sheet. It may seem like the easy way to enter data; however, rarely is every single data point about a woman in labor and the fetal heart rate (FHR) exactly the same from one assessment period to the next and most certainly not the same for hours and hours. The retrospective review that comes with a professional liability case quickly focuses on the multiple discrepancies between what has been copied and pasted and what was actually going on with the mother and fetus as reflected via the FHR tracing. These issues can make the difference in the outcome of the case.


Most nurses are aware that the EHR's audit trail provides information on when and where data were entered. No one on the leadership team has the time to be constantly monitoring these issues; however, if there is an adverse event, retrospective review will use these data to build the timeline leading to the event. Further revealing are data from nurse locator systems that can fill in the gaps as to where the nurse was at all times, not just when documenting in the EHR.


The primary purpose of the medical record is to communicate and share the patient's initial and ongoing condition, treatments, medications, and plan of care with other members of the healthcare team. Even though billing and coding and adherence with standards from the Centers for Medicare and Medicaid Services and accreditation agencies have been added as purposes, communication among the clinical team remains the most important. Lack of careful attention EHR data entry puts this communication at risk, and therefore the safety of mothers and babies in our care.


Safety Considerations When Entering Data into the EHR

Documentation should reflect critical thinking and knowledge of the clinical situation unique to that patient


Copy-and-paste features should be used sparingly, if at all, due to potential for error


A visual and hands-on clinical assessment works best rather than remote patient assessment from data displayed electronically at the central nurses' station


Enter data as close to the time of assessment/care as possible and in the patient's room as appropriate


Be careful when reviewing scanned prenatal records and transferring information into the EHR.




Simpson K. R., Lyndon A., Wilson J., Ruhl C. (2012). Nurses' perceptions of critical issues requiring consideration in the development of Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Journal of Obstetric, Gynecologic and Neonatal Nursing, 41(4), 474-482. doi:10.1111/j.1552-6909.2012.01383.x [Context Link]