47117 Mock Trial: Copycat Documentation Part 2

Course overview

Discussion of the importance of proper and thorough documentation of all patient care provided, the risks associated with drag and drop charting in the electronic medical records (EMR), and the importance of effective communication within the healthcare team to prevent adverse patient outcomes. In the healthcare sector, effective teamwork and communication are essential in order to provide safe and effective care, and ineffective communication is a major cause of errors and adverse outcomes in patient care. Communication errors may occur on many occasions, including patient handover between nurses, which may lead to differing perceptions of a situation and incorrect treatment. In addition to verbal communication, healthcare staff also rely heavily on patient information documented in the patient’s electronic medical record (EMR) in order to ensure patient safety and continuity of care. Documentation facilitates real-time communication within the healthcare team, and when documentation is incomplete or inaccurate, patient safety may be jeopardized due to misinformation and subsequent incorrect treatment. According to the Joint Commission, it is documented in literature that there is widespread use of the copy and paste function (CPF) by healthcare professionals when documenting in the EMR. While using the CPF does have its benefits, these benefits must be compared to the multiple risks in order to preserve the integrity of the medical record. With increasing widespread use of the EMR, the potential for patient harm and adverse outcomes is increased. This program presents the negative consequences which occurred as a result of miscommunication and inappropriate documentation, with the goal of educating healthcare professionals regarding how critical it is to communicate effectively and document thoroughly in order to achieve best patient outcomes.