Nursing is a quickly changing profession that has been vital to providing care in the medical setting. Throughout the past several years one of the most notable changes in the nursing field is the conversion from paper charting to electronic forms of documentation. This has lead to a decrease in the amount of paper charting by allowing nurses to use check boxes, cell formatting, and computer databases to keep patients records more accessible and organized. As new forms of technology become available we find that there are often flaws that need to be assessed and corrected to properly implement an optimal computing system. The clinical integration paper examines the positive and negative aspects of electronic documentation in the nursing field as it pertains to time management, patient safety and its efficacy.
While studying it was found that nurses spend the largest proportion of their time at the nurses station documenting and coordinating patient’s care with thirty nine percent or two hundred and fourteen minutes devoted to that (Hendrich, Chow, Skierczynski & Lu, 2008, p. 25-34). This is alarming knowing that approximately four hours out of a twelve hour shift is done sitting in front of a computer documenting the days events. At Central Baptist Hospital I would think that more then four hours could be taken up by computer charting. From what I have experienced a nurse may begin their shift with anywhere between four to six patients. These patients require a general assessment upon arrival on shift followed by detailed documentation from their nurse. As a student it took roughly thirty minutes to enter an assessment into the computer. Once one is aware of the system it can be entered in about fifteen minutes. However with fou...
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...nic nursing documentation improves the quality of care provided to hospitalized patients remains unknown (Kelley et al. 2011). Overall this document did provide an extensive amount of useful information that was helpful and easily interpreted.
In final consideration electronic documentation has some negative impact on quality patient care. Although quickly becoming a new standard of practice it still has deficient’s that need to be address and fixed prior to implementation in hospitals, clinics, or offices. Hospitals need to include nurses in decisions on electronic documentation so they have the opportunity to learn prior to implementation, limiting time spent on documentation. With documenting becoming the new paper charting it’s imperative that further assessment be made to create an optimal working environment resulting in a higher standard of patient care.
The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet specialized the reporting needs of the nurses on the Women and Infants divisions. Consequently, an application enhancement request was submitted. The goal of this project is to synthesize the knowledge gained throughout this Masters Degree program to initiate, plan, and execute changes to the current clinical documentation system to provide a standardized Clinical Summary review screen to meet the specialized hand-off reporting needs of the nurses on the Women and Infants divisions at BJH. This paper includes project objectives, a supporting evidence-based literature review, project methodology, formative and summative evaluation criteria, and a graphical timeline with a narrative description for the Women and Infants Clinical Summary project.
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
Historically, physicians and nurses documented patients’ health information using paper and pencil. This documentation created numerous errors in patients’ medical records. Patient information became lost or destroyed, medication errors occur daily because of illegible handwriting, and patients had to wait long periods to have access to their medical records. Since then technology has changed the way nurses and health care providers care for their patients. Documentation of patient care has moved to an electronic heath care system in which facilities around the world implement electronic health care systems. Electronic health records (EHR) is defined as a longitudinal electronic record of
However, for any medical record to serve the purpose for which it is meant for, it has to be “contemporaneous, unambiguous, legible and accurate” (Dimond, 2005). Accuracy of records could be described as the most important factor when it comes to record keeping practice in nursing. This is because accuracy in nursing records and documentation provides a real timeline information of the various stages of care provision. Prid...
Working as a professional registered nurse in the hospital, I realized how nurses struggle to find balance between devoting the time charting on the computer and spending time taking care of the patients. Moreover, I’ve seen nurses where they get discouraged trying to find this balance between patients and charting. As a bedside nurse, I would love nothing, but to tend to the needs of my patients. The length of time consume on electronic charting all day, take the very essence of bedside nursing away from nurses, which is caring. Reducing the time of nurses being occupied on charting by eliminating redundant tasks while conforming to their standard, are the changes I would like to make. These are a few of the reasons why I wanted to pursue a degree in informatics. I would advocate for nurses everywhere and to become an instrument in providing them a better electronic health system to work on. Pursuing the degree in nursing informatics will benefit me in
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
The authors consist of nurses, specifically: a Chief Nursing Officer, a Nursing Informatics Officer, and a Dean/Professor of Nursing at Belmont University. The article described how vital nursing documentation is to achieve optimal patient care, including improving patient outcomes & collaborating with other healthcare providers. Using Henderson’s 14 fundamental needs as a framework for their research, the authors proved a definition of basic nursing care and incorporated it into an electronic health record. The authors utilized a team of 16 direct care nurses who were knowledgeable with documenting ele...
The ASF at my precepting healthcare facility used multiple forms of nursing documentation including both hardcopy and electronic methods. Oftentimes the hardcopy nursing notes would be discarded after the information was entered into the Computerized Patient Record System (CPRS). The task to develop an effective electronic nursing note that would eliminate the need for duplicate documentation on hardcopy forms and decrease the amount of time spent charting was initiated.
Retrieved from: Ashford University Library Boaden, R., & Joyce, P. (2006). Developing the electronic health record: What about patient safety? Health Services Management Research, 19 (2), 94-104. Retrieved from http://search.proquest.com/docview/236465771?accountid=32521.
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
McBride, S., Delaney, J., & Tietze, M. (2012). Health Information Technology and Nursing. American Journal of Nursing, 112(8). Retrieved from http://www.nursingcenter.com/lnc/pdf?AID=1402619&an=00152258-201301000-00010&Journal_ID=&Issue_ID=
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
Healthcare is constantly changing with the intention of improving patient care. The Institute of Medicine (IOM) issued a report introducing five core competencies for health professionals, in order to improve the Untied States healthcare system: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics (Institute of Medicine of the National Academies, 2003). IOM proposes that if all five core competencies are utilized by health professionals, quality patient care can be achieved. The facility in which this nurse work, is in need of improving their charting system. The facility currently utilizes two different software systems for charting, in addition to
Technology is stated as the scientific method and material used to achieve a commercial or industrial objective. To go one step further, nursing technology is using a tool to advance nursing practice. “The Institute of medicine identified that technology as a viable method of enhancing patient care delivery and improving staff productivity” Sensmeier, Horowitz (2003 page). Because inadequate nursing staff causes shortcuts to be taken, there are mistakes made that could have possibly been prevented. Errors by nursing staff were variously reported as being responsible for between 44,000 and 98,000 hospital deaths per year. Sensmeier, Horowitz (2003). Technology can have a large impact on nursing. In the past 5 to 10 years, computerized patient records have increased less than 10%. This number shows us that we are still not embracing technology to its full potential. Today in most hospital systems computerized electronic charting is being used. Many hospitals have many different systems for...
To effectively use the Electronic Health Record, the nurse needs to have knowledge of technology in addition to clinical competency (Linder, e.tal, 2007). This is a common barrier of implementing the Electronic Health Record. Initially, the conversion from paper charting to electronic charting is frustrating, this is particularly an issue for veteran nurses. Veteran nurses are use to a routine, documenting in pen and paper is the only method of documenting they have ever experienced. Nurses are trained and educated with a protocol-based and systematic methods of caring. The implementation of the Electronic Health Record presents a change in the way nurses care for patients (HIT, 2015). Veteran nurses that have worked in the healthcare system for over 30 years and have always used paper charts, now have to re-learn how to chart with the Electronic Health Record (Anders & Daly, 2010). Understanding the nursing related barriers of implementation of the Electronic Health Record is