Pre-Populating EMR’s - A Recipe For Disaster
By: Richard Curtis
This is a true story that indicates the dangers of pre-populating electronic medical records (EMR) with canned or default information. A hospital was undergoing a CMS validation survey. The surveyor was reviewing the medical record of a 75 year old male admitted for congestive heart failure. The patient was also noted to have a history of peripheral vascular disease (PVD).
The hospital's EMR is built in such a way that when a care issue is chosen from a drop down menu (in this case PVD), the computer automatically populates both a canned list of nursing assessment interventions as well as "normal" assessment parameters. Staff have the choice of simply clicking one box to accept the default data, or go individually through each data element and select that which is appropriate for the patient. Want to guess what option the admitting nurse chose? Yes... the former.
So, this patient's care plan contained an intervention requiring nursing to check the patient's pedal pulses and circulation each shift. The computer automatically entered the default "normal" into the record. This stated that the patient's pedal pulses were palpable and that there was good capillary refill in each foot.
Sounds great... what a time saver! Only problem was, the patient was a bilateral amputee from the knee down. Try explaining to a surveyor how a nurse documented the presence of pedal pulses on a patient with no feet!
It got even worse. The hospital's EMR also had the ability for a nurse on one shift to replicate the documented assessment by a nurse on the previous shift. This "carry forward" function was another great time saver. So, again, rather than documenting their own assessment each shift, nurses over a three day period simply copied the prior shifts assessment. Now the hospital had to explain how multiple nurses on multiple shifts documented pedal pulses on the patient.
Long story short, the hospital was placed on an immediate threat to health and safety, and CMS moved to decertify the hospital from Medicare. The moral of the story? If your EMR pre-populates, you do so at your own risk. There needs to be balance between using the EMR to save time, and assuring that the medical record is accurate and reflective of each patient's individual care needs.
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