1. McCartney, Patricia R. PhD, RN, FAAN

Article Content

Labor nurses often describe the challenge of providing maternal support during second-stage pushing while also meeting the responsibility for timely, accurate, and complete medical record (MR) documentation. Nurses who work in intrapartum units are acutely aware of the importance of the MR as evidence that the standard of care was met, and nursing publications provide guidance about documentation content to support the standard of care. Beyond content, what might nurses need to consider when documenting in an electronic medical record (EMR)? Capturing data electronically transforms the MR from a "document" to "data" in dynamic formats, (unlike paper), and increases the amount of data available as evidence in a legal review. Electronic discovery (e-discovery), or the legal request for and subsequent release of electronically stored information, is a hot topic in the medical records arena. One product of e-discovery is an audit trail of nursing documentation.


Audit Trails

Medical record audits are not new to nursing; the American Nurses Association has stated that documentation must be accurate and consistent, timely and sequential, and able to be audited (American Nurses Association, 2005). Audits are now a regulatory requirement with electronic documentation. To protect the security of patient data in the EMR, the Health Insurance and Portability Accountability Act (HIPAA) requires healthcare organizations to monitor data access (who views the EMR) and data integrity (data cannot be altered without detection) (McCartney, 2003). One strategy to accomplish this requirement is audit functionality.


The audit function records the identity of each information system user, the date and time of access, and what the user did (view the record, create an entry, edit an entry, or delete an entry). Because user access is recorded, the audit provides nonrepudiation, meaning that the user cannot deny accessing the EMR. The audit function can track documentation entries, corrections, and changes. An audit report is a chronological review of patient data, alerts, and entries in the EMR and can be used to identify breaches in security and provide evidence for legal review (Dougherty, 2008). Audit functionality safeguards patient information and ensures trustworthiness of the record.


Electronic Documentation

The labor nurse often needs to delay some documentation until after the birth and may need to edit or add to previous documentation. Considering the ability of the EMR to track documentation entries, consider these general steps to take for best practices:


* If you need to make a correction, addition, or late entry, do so as soon as possible.


* Like paper documentation, the original entry must remain viewable and not be deleted.


* To correct a previous documentation, enter the current date and time you are making your entry, record the reason you are making the correction, identify the date and time of the original entry you are correcting, and then enter your information.


* To enter an addendum, enter the current date and time you are making your entry, state "addendum" and the reason you are adding additional information to the original entry, identify the date and time of the original entry, then enter your added information.


* To enter late documentation, enter the current date and time you are making your entry, state "late entry" and the circumstances for the late entry, then enter your information and indicate the actual time that events occurred.



Ask about specific functions for corrections, addendums, and late entries and audit trails in your EMR. Share your thoughts about these functions with a letter to the editor!!




American Nurses Association. (2005). Principles for documentation. Silver Spring, MD: Author. [Context Link]


Dougherty, M. (2008). How legal is your EHR: Identifying key functions that support a legal record. Journal of AHIMA, 79(2), 24-30. [Context Link]


McCartney, P. (2003). HIPAA and electronic health information security. MCN The American Journal of Maternal/Child Nursing, 28, 333. [Context Link]