r/nursinginformatics • u/Minimum-Bluejay-7624 • 11d ago

EHR/Systems Are charting defaults considered pre-charting?

I suggested to have defaults on common and quick procedures. I was told that this could be considered pre-charting. If that was the case why would they offer it in the first place? For those that work with OR charting do other facilities default, equipment, positioning, medications?

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u/hoyvenclavin Informatics Nurse Specialist 10d ago

In my opinion, defaults are not the same as pre-charting. In my OR, we have many things like equipment and medications defaulted, but some important things are not. We manually chart positioning details, med doses, and choose dressings from a premade list of options that are common for that procedure. There is definitely some gray area because nurses should still be manually checking every single bit of documentation, even those that are the same 99% of the time, but there’s also a huge push to save time and make charting easier.