Practices for accurate documentation
Use these product practices to prevent common drafting errors
Corrections. If you need to correct something you misspoke, simply say it again. The last observation spoken is the one that is documented.
Timing limitations. After you select a filing column, verbalizations such as "pulse was 75 at 1900" won't move the entry. This limitation doesn't apply to device addition and removal times, which support verbalization.
Background noise. Mute the television and use the pause function during sidebar conversations that shouldn't be part of the recording.
Glasgow Coma Scale. A total score of 15 is supported by saying "GCS 15." When the score is abnormal, state each of the individual Eye, Verbal, and Motor subscores and the product calculates the total.
Review before filing. The drafted flowsheet is a draft. You review it, edit it, and file it. The transcript is available temporarily to support your review and isn't part of the permanent record.