mented are on the rise.
With autofill, it's all too easy to make charting errors. Typing in a let-
ter or two and hitting enter can bring up a wrong word. As an exam-
ple, a review of GI system will bring up specific symptoms, such as
appetite changes, nausea, vomiting and abdominal pain. If there are
symptoms, the auto-population feature can choose those words.
Plaintiffs are now claiming that nurses never asked those questions.
And it's easy to spot misuse of auto-population by searching for incon-
sistencies in the record.
Always double check your auto-population when charting and make
sure you have the correct information before finalizing the entry. A
permanent electronic record of everything that you document exists
and you cannot make it go away by crossing out or deleting.
Copy and paste. The copy-and-paste feature is a convenient way
to transfer data, but incorrectly copying the source data or the
source of the data could result in an error within a patient's chart. It's
easy to see what other nurses have charted before you and you may
be tempted to just copy what they documented, especially when noth-
ing has changed. Besides, you assure yourself, you can always review
and edit anything that is different from one patient to another.
Another copy-and-paste danger is copying a snippet of a sentence.
An expert can easily spot duplicate blocks of information across mul-
tiple charts. It suggests that you're taking shortcuts and speaks vol-
umes about your nursing care. In one case, a patient was listed as hav-
ing a history of "PE" (pulmonary embolism), although the patient
denied this. After reviewing the chart, it was found that "PE" had orig-
inally been used for "physical exam," but was mistakenly listed under
medical history and propagated throughout the chart for years.
In another case, a patient who was receiving chemotherapy was
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