Last Updated | August 31, 2021
Clinical documentation is needed to improve quality of care, enhance clinical outcomes, maximize efficiency, ensure patient safety, and facilitate inter-professional communication. As such, nursing documentation provides an accurate picture of nursing assessments, care plans, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary teams to deliver great care. Nurses use accurate documentation formats to share accurate, timely, and organized information about patients and organizational functions.
The most common of those formats is the Electronic Health Records (EHR) which are used as a real-time method of informing the health care team about the patient status. A patient’s EHR contains pertinent information that helps the health care team make informed decisions and ensure high quality care in the continuity of patient care. An EHR contains up-to-date information on patient assessments, clinical problems, clinical reports and lab results, communications with other health care professionals regarding the patient, medication records (MAR), immunization dates, allergies, radiology images, Patient clinical parameters, Patient responses and outcomes, and their entire medical history.
Nursing documentation using EHR is important since complete, timely, accurate medical record keeping ensures that patients get the right care at the right time. It is impossible for any nurse to remember everything that happened on a shift. Without clear and accurate nursing records for each patient, handover to the next team of nurses will be incomplete. Best records contain relevant information about the condition of the patient at any point, as well as the measures the nurse has taken in response to the patient’s needs.
Studies have linked electronic health records (EHRs) with a positive ROI and improved organizational efficiency in nursing. Nurses are on the front lines of patient care, which means that they must have vital information regarding a patient’s health history, previous and current medications, allergies, family history, and any other pertinent information on hand, so that they may administer proper care. When nurses have quick, easy access to patient records, they save time that would otherwise be spent locating paper charts, or when nurses are alleviated from having to manually enter information into patient records. Similarly, the use of a standardized record format, such as EHR, helps nurses in efficiently documenting patient notes by using wizards and templates for faster data entry. Another area where EHR improves efficiency for nurses is reporting Critical lab values to the healthcare provider in a timely manner. The EHR flags each critical value for clinical staff, making notifications simpler for nurses. Electronic health records also help nurses in other ways, for instance by sending medication reminders, preventing drug interactions, giving immediate access to patient medical history and medications, documentation of clinical care.
Nurses are on the front lines of patient care. According to a Survey of NPs, most nurses asserted that the implementation of EHR allowed them to better monitor patient progress, improve accuracy in their work, and enhance productivity. By gaining timely and hassle-free access to patient’s records and orders prescribed by physicians, nurses are better to deliver quality care to patients and meet all their needs. At a study conducted at a tertiary medical center, it was found that nurse satisfaction boosted manifold after EMR implementation, especially due to ease of documentation, reduced workload, improved patient safety, better collaboration with co-workers, and medication information accuracy. According to NPs, EHRs allow them to monitor patient progress and decrease their workload overall. In short, the EHR gives NPs comprehensive data that can guide them to more accurate, reliable care.
Numerous studies prove that nurses save 24% of time otherwise spent on documentation by using EMR. This boosts job satisfaction and allows nurses to perform additional patient-centered care. With all this time saved on documentation, hospitals may be able to reduce nursing staff and cut down on costs. Not to mention, improved patient outcomes will inevitably lead to less medical errors and reduced lengths of stay. A study found that using an EMR to capture vital signs of patients with connected devices, resulted in significant reduction in time to make the data available for review and even reduce transcription error. This frees up a significant chunk of an NP’s time, with can be spent on delivering better care to patients.
One of the most important tasks of nurses is to safely administer medications to patients. However, nurses are not immune from medication error and near misses. Medication errors can impair patient safety and may lead to litigation down the road. Using EHRs is a sure-fire way to avoid medication errors. EHRs also reduce adverse drug events by 52%. Some are designed to integrate with bar code scanning technology; if a nurse scans the wrong medication, an alert pops up alerting him or her to a problem. Not to mention, illegible handwriting was previously one of the major culprits of medical errors. Historically, more than 60% of medication errors in hospitals were attributed to poor handwriting. With the introduction of EHRs, writing is no longer a concern.
To see how EHR improves documentation, we have to revisit the inefficiencies and drawbacks of paper records. First things first, illegible handwriting led to a majority of medical errors and paper document cannot be electronically shared or stored. Not to mention, disparate paper records contained unstructured data that is not computable and cannot be shared with other systems. Paper documents were also expensive to copy, transport and store, could be irrevocably destroyed in the events of a calamity, and proved difficult to analyze. Electronic Health records not only bid adieu to the problem of legibility but are unbelievably easy to share and access.
EHRs are much better organized than paper charts, allowing for faster retrieval of lab or x-ray results. Not to mention, EHR contain updated list of each patient’s major illnesses, surgeries, allergies, immunizations, diagnoses, treatments, and medications. Using EHRs minimize repetition of unnecessary tests and prevent healthcare staff from administering medication that may react adversely to a medicine a patient is already taking. Previously, 20% of laboratory tests were re-ordered because previous studies were not accessible. Thankfully, EHR documentation is the answer.
Using an EHR and hl7 integration services, doctors could easily navigate through the entire medical history of a patient. No more pulling out cabinets to frantically search for paper charts or lab results when all the information is available at the click of a mouse, 24 hours a day, seven days a week. Not to mention, since healthcare facilities no longer need extra space to store patient files, record rooms could be transformed into more productive space, such as exam rooms, thus increasing patient flow in hospitals. Importantly, electronic health records can be accessed by any person in a patient’s chain of care, be it a billing clerk or a primary care physician and a specialist. Moreover, patient information can even be made available to visiting doctors to help them review patients who are not in their panel. EHR records also include templates that help remind clinicians to add more history or details of the physical exam, thus making sure that no detail is missed. Thus we can say that EHR promises a completeness of clinical histories. EHRs reduce redundant paperwork and have the capability of interfacing with a billing program that submits claims electronically.
Electronic health records also take the cake for their ability to integrate for sharing with health information organizations, healthcare consulting firms in California, and with analytical software for data mining to examine optimal treatments. Last but not the least, all this treasure trove of information can be made available to researchers to speed of the research cycle and “rapidly inform clinical decisions.
Surveys have revealed that nurse practitioners are hesitant to adopt EHR due to several reasons. For instance, it is important for healthcare staff to maintain eye contact when communicating with patients. In one survey of nearly 14,000 nurses, 69% stated that their EHR is time-consuming and takes time away from their patients. However, NPs have to turn away from a patient to use the EMR or EHR, leaving the patients feeling ignored, and may potentially interrupt important discussions about a patient’s health status, test results, or prescribed medications. Not to mention, EHRs from some healthcare mobile app development company may come with rigorous data entry requirements, and difficult-to-navigate user interfaces do not any easier for NPs to adapt. To add their troubles, factor in auto-correct or auto-fill functions, not enough hand-held devices used to bar code scan medications, and delayed access to laboratory results could lead to medication errors which can compromise patient safety.
Secondly, NPs need updated, real-time data for clinical decision-making, making it impossible to deliver care if only partial or incomplete medical data is accessible, such as when a system is offline. A lot of NPs complain that widespread adoption of EHRs could lead to increased errors and malpractice liability. For instance, EMR systems do not have a template for every disease process or condition. Templates that do not allow entry of data suggesting alternative diagnoses could expose the NP to potential litigation. Similarly, it is really difficult for NPs to capture all pertinent information in the EHR in real time, which is the entire purpose of the EHR in the first place. This can lead to post-visit addendums, corrections, retractions, deletions, which can land the NPs in hot water down the road. Auto-fill functions can sometimes inaccurately complete fields which the NPs are not aware of. The same applies to dictation errors. Drop-down boxes used for documentation also limit the ability of the NP to chart information.
Electronic health records are mainly used by nurses to get medication reminders, prevent drug interactions, gain immediate access to patient medical history, and documentation of clinical care. Nurses need to constantly monitor patients and record assessments, care plans, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary teams to deliver great care. Overall, EHR adoption had a positive effect on the hospital’s nursing staff.
When health care providers have access to complete and accurate information, patients receive better medical care. Electronic health records (EHRs) are popular for their ability to support research, clinical decision, diagnoses and in reducing medical errors and improving patient outcomes. As for the field of nursing, EHRs provide treasure trove of data to support comparative effectiveness research and new trial designs that may answer relevant clinical questions as well as improve efficiency and reduce the cost of clinical research. Adoption of HER is leading to improvement in all clinical quality measures in healthcare facilities.
Electronic documentation contains flow sheets that help in assembling information about the patient’s needs, improve the patient’s information accuracy, and enhance the quality of patient care, as well aid NPs assessment, nursing diagnosis, planning, implementing, and evaluating.
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