Nursing Documentation and the Electronic Health Record
There is enormous pressure on all health care providers to document care in a succinct, accurate, and focused manner towards clinical outcomes. Due to the metamorphic nature of America’s health care system, it comes as no surprise that patient care documentation must follow suit in moving from paper-based charting to the digital era of computerized charting. The electronic health record (EHR) is the way forward for patient care documentation and, as such, should tell the comprehensive story of quality care provided to patients.
The Nurse’s Role in Documentation
The nurse’s role is not just about providing care, it is about accurately chronicling the processes, events, and interventions leading up to the desired outcomes of treatment. Documentation is at the core of nursing practice and is the main tool available for communicating care provided to patients. Documentation is a fundamental but critical skill used by nurses to communicate the care patients receive, their response to that care, and any need for further treatment or follow-up care. In fact, appropriate and effective documentation is at the core of the nursing practice. Although documentation was always an important part of nursing practice, today’s increasingly complex healthcare environment, litigious society, and the diversity of settings in which patients receive care require that nurses pay more attention to documentation. In addition, many people, including direct and non-direct patient care providers, depend on nursing documentation to make important clinical decisions. Further, when nurses perceive documentation as a time-consuming nuisance, this attitude can put patients, staff, and organizations at considerable risk of physical and legal harm. Further, a negative attitude towards documentation of care can lead to hurried entries that lack depth and detail which risks missing the recording of important data which can potentially lead to poor patient outcomes (Blair & Smith, 2012).
A number of research studies and anecdotal accounts address the issue of poor nurse documentation and its effect on the quality of patient care. The problem, as described by Mahler et al. (2007) of why nursing documentation is lacking in quality is that the nursing process is not integrated into nursing documentation. One reason cited is the limited acceptance of the nursing process. According to the National Patient Safety Agency (2007), incomplete and inadequate documentation were identified as a contributory factor in the failure to detect patients who were clinically deteriorating. These problems lead to the attempt to support nursing documentation by computer-based systems in order to reduce documentation efforts, increase documentation quality, and allow reuse of nursing data for nursing management and nursing research. As a result of the implementation of EHR across America’s hospitals, nurses are becoming more cognizant of the need to improve their documentation of the care they deliver to patients daily.
Paper-Based versus EHR
Just imagine an earlier time in nursing when the norm was paper-based charting, to include narrative notes and flow sheets. These notes, after completion by nurses, doctors, and other healthcare providers on the patient care team, would be placed in the patient’s medical record under separate sections. Contrast this to the EHR system. The same concept prevails with each provider charting in the patient’s record with the exception that the record is no longer a hard copy but a digital one. The traditional method of paper-based charting differs from the computerized version in that, rather than detailed narrative notes addressing the patient statues, nursing interventions, and responses to those interventions, the EHR is charting by exception and limited nurse narrative. This means documentation is limited to only significant or abnormal findings in the narrative portion of the record. Other features of the EHR are the capability to copy and paste previously charted data and structured drop-down menus with predetermined choices. These features are concerning because of the potential ethical and legal ramification that comes with them. Ethical and legal ramifications will be discussed in part two of this series.
Nurse and Computers
A recurring theme after analyzing several peer-reviewed articles relating to nurse’s experiences adapting to EHR systems revealed a nurse’s perception was a key factor transitioning from paper-based charting to using an EHR system. A recommendation, therefore, is for nurses to reflect on how they perceive using EHR systems and check whether or not their perception is affecting their ability to chart accurate and timely information on care given to patients. Another consideration for nurse’s caught up moving from a familiar paper-based charting to a computerized system is to note whether or not the experience is positive or one fraught with high resistance. It is reasonable to conclude that nurses who did not grow up with the same degree of technology are more uncomfortable with using computers than their younger counterparts who grew up in the technology age. Additionally, competent nurses can feel like novices when first charting with an EHR system. To address these needs to help nurses perceive using computers in a positive light, organizations can provide ongoing education and training to nurses at different intervals which can increase a nurse’s confidence in computer skills.
The EHR System
The EHR system is identified as a strategy for effectively and efficiently coordinating and maintaining the documentation of patients’ health histories, and as a method of helping providers make informed clinical decisions. EHR is advanced as a mechanism for transforming nursing care, enabling nurses to function as knowledge workers, with the potential of making nursing care less stressful, more satisfying, more research-based, and more visible. Understanding and managing facilitators and barriers to the adoption of EHR systems can impact a nurse’s ability to provide and document nursing care. Additionally, managing barriers will greatly assist nurses in improving their documentation; whether it is using a paper-based system or an EHR system.
Blair, W. & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse 41(2), 160-168. doi: 10.5172/conu.2012.41.2.160
National Patients Safety Agency. (2007). Recognizing and responding appropriately to early signs of deterioration in hospital patients. Retrieved from https://www.patientsafetyoxford.org/wp-content/uploads/2018/03/NPSA-DeteriorPatients.pdf