I recently began working in a facility with a fairly long history of EMR use. The PICC team continues to do almost all of their assessments and in, duplicate documentation, the placement information on the same old forms they used for years. These are kept in a locked office but otherwise unsecured. My belief is that we become invisible as nurses when we fail to document our assessment and decision making in the EMR. Unfortunately, this is not the first hospital I’ve worked in that follows the same practices.
Does anyone have a standardized assessment for the EMR? Is there any reason to double document insertion info in the EMR and on a piece of paper?
I do realize change will be difficult. I believe it needs to be done or we will become invisible. The knowledge and expertise needed for PICC and other vascular placement needs to be seen to be valued.