For the Record

     In this present day of increasing litigation in the area of wound prevention, diagnosis, and treatment, the WOCN is frequently called upon to be involved in at least one aspect and sometimes several aspects of  Electronic Medical Record (EMR)documentation.  The experienced WOCN may have his or her own charting reviewed by agencies, law firms, juries, and colleagues.  The WOCN may be the one who reviews records for evidence of care.  Staff members including physicians, coding specialists, legal services, and nurses rely on the WOCN to serve as a resource for the essential components that must be included in the electronic medical record.

      When President Obama signed the 2009 American Recovery and Rieinvestment Act into law, it included stimulus funds for the development of Electronic Medical Records (EMR) by service providers and hospitals.  Paper charting is fading away as new systems for EMR are increasingly the sole source of patient information.   When the EMR is reviewed there may be inadequate or inconsistent documentation to support the level of care that was provided.  The printed appearance of an EMR presented for review may not be easy to decipher.  WOCNs must develop proficiency at utilizing the EMR.

      This poster will discuss the components of the EMR that must be present to ensure defense against litigation.  Several WOCNs involved in record review and legal defense will be interviewed to discuss the problems and shortcomings of the EMR most often encountered.  Review of the poster by WOCNs from a variety of settings will assist them to identify and rectify areas of practice and documentation that may need implemented in their own facilities.