Electronic medical records (EMRs) and paper medical records are profoundly different. The age-old saying pertaining to nursing documentation and liability in the paper world was, “If it wasn’t documented, it wasn’t done.” This statement, of course, was and is not accurate. Although comprehensive and complete documentation may be the goal, the reality is that nursing care is sometimes performed and not documented, sometimes for legitimate reasons.

Today in the electronic world, there are lots of built-in documentation choices. If a nurse is not familiar with or cannot readily recall where all potentially relevant choices are, will she or he be held accountable for something not documented? This challenge is accentuated when an excessive number of rarely used or unused built-in choices require nurses to wade through numerous screens and volumes of content to find what they need. Perhaps the built-in choices are not...

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