Nursing Notes Document Management and Guidelines

The organization of nursing notes requires serious consideration of numerous factors, including the latest regulations, compliance measures, and ensuring that defensible medical records are created. Those who are new to the field may feel overwhelmed by the process of creating and storing their notes, while those who have spent decades in the nursing field can often be resistant to changing their antiquated methods to the latest technologically-sound options, but the truth is simple: The physical storage of medical files has limitations, complications, and serious security issues. Fortunately, there is now an alternative.

Best Practices for Storing Nursing Notes

There are many specific tips for ensuring compliance and following regulations that may be specific to the particular type of client a nurse works with, or the office in which he or she works. However, these tips for organization apply to everyone in the nursing field.

  • Organization is key. A patient’s name and/or internal identifying number should be on every page of notes.
  • Skip sticky notes. They can easily come off and critical information can be lost.
  • Every note should begin with the reason for a patient’s visit. Sign or initial every chart entry.
  • Write legibly and remember that many physicians and other nurses must be able to make sense of every note that is written.
  • Electronic medical records can make organization much easier and more secure.
  • Void or fill in spaces on transcriptions or forms. Blank spaces can be ambiguous.
  • Any time a change is made to a record, several things need to be noted: the person making the change, the reason they changed it, and what they changed.
  • Document phone calls to include the date, name, and content of the conversation.

Difficulties that Occur When Following These Best Practices

Following the above practices is the best way for nurses to create defensible medical records, and to assure compliance with HIPPA and other regulations, but doing so is not without its complications. Those complications include:

  • The overhead cost associated with physical files, which includes paper, copiers, cabinets, and the human capital required to file and find documents
  • The difficulty in keeping nursing files confidential
  • The space required to store files
  • The huge drain on resources that occurs when redundant notes must be stored in a variety of databases and/or locations
  • The cost of sending notes from one office to another and mailing documents to other physicians and to patients
  • The reality that files can be lost or destroyed

Thankfully, these issues with storing nursing files can be combated in a simple way.

Advantages of Using Document Management Software

Upgrading from paper files to document management software (DMS) has many benefits and advantages, including built-in integration with HIPAA. Other advantages include:

Reduce Overhead Costs
While there will be an initial investment required to move from paper files to DMS, it will eventually pay for itself in reduced overhead costs. Many medical practices utilize storage facilities, which are no longer necessary when everything is digital. Other costs of using paper files include:

  • Ink
  • Paper
  • Postage costs
  • Human capital spent filing and retrieving files

Increase Security
Document management software keeps your files secure. Filing cabinets can easily be broken into, and paper files can be damaged, destroyed, or permanently misplaced. With a paperless office, your files are backed up and encrypted to prevent virtual theft and loss due to power outages, natural disasters, and other events. The top DMS will also offer role-based security, which means medical offices can allow different users access only to the virtual folders, files, and drawers that are relevant to their job.

Track a Document’s History
Compliance requires strict control over who accesses documents and who adds notes. A DMS has the ability to track the history of any document and identify who changed it, when they changed it, and what they changed. When defensible medical records are a priority, DMS that can track these changes is a must.

Avoid Redundancy and Increase Consistency
It’s no longer necessary for nurses to enter their notes in 2, 3, 4—or more—systems. Using DMS streamlines the process to ensure that everyone who needs access to the notes can access them from their own location. This reduction in redundancy also means an increase in consistency. All members of a team are using the same software and can follow identical protocol.

Seamlessly Integrate with Third-Party Software
The right DMS allows for seamless integration with a wide range of business applications, including Microsoft Office programs. This integration further saves time and allows offices to be as efficient and productive as possible.

eFileCabinet Offers Comprehensive and Intuitive Features

Though medical offices have several DMS options to compare, a close look at eFileCabinet makes it clear that we have everything you need:

  • Leading-edge 256-bit encryption for total security of all notes and documentation. For example, a scope of treatment form would be safe and secure and can be given role-based permissions to access it.
  • Built-in compliance with HIPAA makes it simple to follow the latest regulations and ensure compliance.
  • eFileCabinet offers integration with third-party software including all Microsoft Office programs, QuickBooks, CRM tools like Salesforce, and dozens more.

Fill out the form on this page for a 15-minute demo that will demonstrate exactly how eFileCabinet is revolutionizing the world of document management.

By | 2016-12-15T11:59:28+00:00 November 10th, 2015|
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