Some common challenges of screening medical records include identifying missing information, understanding the organization, or lack there of, as well as deciphering illegible handwriting.
As a nursing school instructor, I have taught hundreds of nursing students about documentation, specifically what to document and how to read a medical record. Unfortunately, the development of the EMR has provided a skewed understanding of documentation standards. Many staff believes that as long as they document in the required fields (i.e. check boxes) provided within the EMR system approved by the institution, that they are providing an appropriate level of documentation. However, no system can be fully equipped with every safe guard applicable to any situation that may occur in a healthcare facility. It is still the standard of practice to document when an adverse event occurs, regardless if there is a corresponding check box.
This leads me to the issue of organization. Every EMR system is different and has its own pattern of organization. When an electronic chart is printed in it’s entirety, it may not appear to be in any obvious order. This can make it difficult to identify what events occurred or whether anything is missing. A legal nurse consultant can identify what is missing because we know the anatomy of the medical record and what should be present. Whether it’s a paper chart or EMR, one of the first things I do when I review a medical record is organize it and audit all necessary components to ensure the chart is complete.