Information technology is constantly evolving. Among the most common types are electronic health records (EHRs) and computerized physician order entry systems (CPOEs). Though these and other information technologies offer advantages, they also pose new challenges and potential risks.Information technology is constantly evolving. Among the most common types are electronic health records (EHRs) and computerized physician order entry systems (CPOEs). Though these and other information technologies offer advantages, they also pose new challenges and potential risks.

When properly implemented, information technology can simplify information retrieval, reduce medical errors, and improve communication, among other pluses. But information technology doesn’t eliminate the need for professional judgment. “People are not infallible. Neither are computers—but we tend to think they are,” said Melanie Balestra, JD, MN, NP, a California-based attorney. Always keep this warning in mind to protect your patients’ health and minimize your professional liability risk.

Some potential pitfalls of EHRs

If your facility doesn’t already use an EHR, eventually it will. Compared with paper records, an EHR can store more information for longer periods. Also, an EHR is accessible concurrently from many workstations and can provide medical alerts and reminders. Despite these and other advantages, an EHR can make one of your key responsibilities—documenting patient care—more difficult. “Traditional paper charting is free-form,” noted Leslie Nicoll, PhD, RN, MBA, editor-in-chief of the journal CIN: Computers, Informatics, Nursing. “EHR charting is more structured; you’re forced to choose from various options in multiple lists. You have to change your thinking about charting.”

That doesn’t lessen your responsibility to document thoroughly and accurately, so you must understand how the system works and use it properly. “For instance, what if you enter something into the wrong patient’s chart?” asked Diane Kjervik, JD, RN, editor-in-chief, Journal of Nursing Law. “How do you correct that? On paper you’d line through the entry once and initial or sign it, but you can’t do that in an EHR. And, if you are able to make a correction, will the system still save the mistake?”