Clinical documentation supports patient care, improves clinical outcomes, and enhances interprofessional communication. When you document your assessments, plans, and actions, you rely on nursing practice standards, organizational policies, meaningful use directives, and a variety of quality criteria.
Electronic health records (EHRs) support that documentation with data that help you enhance patient safety, evaluate care quality, maximize efficiency, and measure staffing needs. And they serve as a standard form of documentation that can be shared by everyone on the healthcare team. However, when not used appropriately, EHRs can reduce nurses’ use of their critical-thinking skills, increase reliance on workarounds to bypass forms, and lead to errors and lost documentation. How can nurses take advantage of the benefits inherent in EHRs and eliminate some of the frustrations?
With that question in mind, the Nurse Practice Council (NPC) explored the prevalence of docu- mentation gaps in our organization, St. Joseph’s University Medical Center (including St. Joseph’s Children’s Hospital), which has received American Nurses Credentialing Center’s (ANCC) Magnet
Care Centered Clinical Documentation In The Digital Environment: Solutions To Alleviate Burnout
Recognition four consecutive times. A close look at our quality department’s reports of near misses validated our suspicions on a range of issues, including human errors in recording heights and weights, missed vital sign trends, and generally poor handoff communication. The new workflow was affecting critical thinking and clinical judgment.
We took our concerns to the NPC where members described feelings of being torn between the priority of patient care and the chores of documentation. Nurses by nature are adaptive, so many resorted to workarounds, completing only mandatory elements, which led to less-than-ideal documentation. They told us that they were frustrated and dissatisfied with the EHR. Through collaboration with the NPC Informatics and Evidence Based Practice Committees, we explored how to improve nursing documentation by re-introducing the nursing process.
Over a period of 3 months, we retrospectively audited patient records from the medical-surgical area for baseline nursing documentation; data elements were analyzed for care decisions and patient safety. The initial work helped identify a number of design gaps, including fields that nurses weren’t required to complete but were essential for quality care. This deficiency was promptly fixed and was an easy win.
Pdf) Exploring The Impact Of Electronic Health Records Systems On The Performance Of A Healthcare Organisation A Qualitative Study In Ghana
After all of the problems were identified, we chose nurse champions who were trained to continue chart audits and proper documentation, using the nursing process model on a larger scale. Training included workshops for proper EHR documentation techniques, record audits, case scenarios, and reflective feedback using Gibbs’ reflective cycle, a tool for helping people learn from situations. (For more information about Gibbs’ reflective cycle, see resources.eln.io/gibbs-reflective-cycle-model-1988/.) With our goal of integrating the nursing process with the EHR, we adopted the American Nurses Association’s definition of the nursing process as “an assertive, problem-solving approach to the identi- fication and treatment of patient problems.” (See
One year later, the project has expanded to many avenues of nursing, including RN orientation, preceptor classes, and individual unit education. Subsequent auditing (3, 6, and 9 months after education) shows improved documentation in areas with significant effect on patient care and safety, including these 3-month results:
As with every change project, leadership commitment is key. Our nursing leaders were supportive of the project and the proposed solutions. However, we encountered some challenges (and developed some solutions), including:
Electronic Health Records (ehr) Research Group
This project empowered our NPC members to evaluate their documentation practices and reflect on what they learned from the audits, quality reports, and data mining. It enabled them to look to their future practices in clinical documentation and follow through with the nursing process. The EHR documentation review and tools have become part of the curriculum for the nursing preceptor workshops and our new hire orientation.
The authors work at St. Joseph’s University Medical Center in Paterson, New Jersey. Janet Pagulayan the nursing informatics coordinator. Salim Eltair is a nursing informatics systems manager. Kathy Faber is a clinical nurse leader and co-chair of EBP Nursing Practice Committee.
Affordable Care Act (ACA). 2010. healthcare.gov/glossary/affordable- care-act Agency for Healthcare Research and Quality (AHRQ). Slide set: National quality strategy overview. 2017. ahrq.gov/workingforquality/nqs/overview.htm
The Benefits And Challenges Of Using Electronic Health Recording System From Nurses' Perspective
Nykänen P, Kaipio J, Kuusisto A. Evaluation of the national nursing model and four nursing documentation systems in Finland—Lessons learned and directions for the future.
Sockolow PS, Liao C, Chittams JL, Bowles KH. Evaluating the impact of electronic health records on nurse clinical process at two commu- nity health sites. NI. 2012:381.
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Exploring The Challenges Of Using Electronic Health Record Systems In Nursing Research
This project empowered our NPC members to evaluate their documentation practices and reflect on what they learned from the audits, quality reports, and data mining. It enabled them to look to their future practices in clinical documentation and follow through with the nursing process. The EHR documentation review and tools have become part of the curriculum for the nursing preceptor workshops and our new hire orientation.
The authors work at St. Joseph’s University Medical Center in Paterson, New Jersey. Janet Pagulayan the nursing informatics coordinator. Salim Eltair is a nursing informatics systems manager. Kathy Faber is a clinical nurse leader and co-chair of EBP Nursing Practice Committee.
Affordable Care Act (ACA). 2010. healthcare.gov/glossary/affordable- care-act Agency for Healthcare Research and Quality (AHRQ). Slide set: National quality strategy overview. 2017. ahrq.gov/workingforquality/nqs/overview.htm
The Benefits And Challenges Of Using Electronic Health Recording System From Nurses' Perspective
Nykänen P, Kaipio J, Kuusisto A. Evaluation of the national nursing model and four nursing documentation systems in Finland—Lessons learned and directions for the future.
Sockolow PS, Liao C, Chittams JL, Bowles KH. Evaluating the impact of electronic health records on nurse clinical process at two commu- nity health sites. NI. 2012:381.
*By submitting your e-mail, you are opting in to receiving information from Healthcom Media and Affiliates. The details, including your email address/mobile number, may be used to keep you informed about future products and services.
