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Transparency refers to the clarity of the record for its users. Transparency, in more recent times, has come to mean the open sharing of information. For purposes here, we define electronic health record transparency as clear and open sharing of information among providers and with patients. While providers using the EHR have access to information inserted by interdisciplinary team members, access to this information is not always intuitive, nor is its presentation always clear.
Systems today do provide patients with electronic access to limited information in their EHRs. However, it is possible that even greater information sharing in the future will further improve the quality of care Delbanco et al. Development of an electronic workflow to standardize and improve communication.
Additionally, the Nursing Practice Committee recommended that the nursing process steps be researched and developed into an abbreviated communication tool, one that would describe and prioritize each individual patient problem for use during handoff at change of shift and also when documenting planning of care during admission, transfers, and discharges. A simple, electronic workflow helps standardize and improve communication of direct care in keeping with the ANA documentation standards , as in the following focused-care example. The purpose of nursing documentation is to record nursing care provided and patient responses.
Because the current standard of care is the nursing process, the steps in the nursing process need to be evident in nursing documentation. When documentation is poor it is likely that both human and technologic improvements are needed. We authors find human-machine interaction to be interesting. When there is an issue with documentation, those closest to the world of informatics are quick to exculpate the EHR by saying it was never intended to fill a gap in practice. On the other hand, those closest to the clinical world are quick to exculpate themselves by blaming one or more technical features of the EHR.
Reality most likely lies somewhere in the middle. It may be that standardization of care processes, including clinical decision-support processes, becomes more fully appreciated as the number of Doctor of Nursing Practice DNP graduates increase. These graduates are prepared to use new quality improvement technologies; organize and analyze the evidence that flows from their own practice; and compare their practice parameters against those of others.
The following paragraph provides an overview of DNP clinical projects designed to improve patient outcomes or reduce patient risk by improving care processes. APRNs, and especially DNP graduates, know that the ability to take advantage of EHR data to improve patient care first requires the proper entry of process and outcome data in the record. Nurses use both synchronous and asynchronous methods to document care.
Perhaps when voice activated, natural language processing methods are further developed and better integrated into the EHR, all nursing documentation will be synchronous. Clinical decision support CDS information depends on real time data. Triggering an alert for sepsis is only beneficial if the alert comes as soon as the system inflammatory response system SIRS criteria are met. If the vital signs are written on paper and entered later, the alert is delayed and patient safety is impaired.
Documentation studies indicate that factors to promote diagnostic reasoning and accuracy have been identified. Researchers should work closely with EHR vendors and terminology developers to be assured that tools with known validity and reliability are correctly incorporated into the clinical workflow.
These scales not only meet nursing and hospital system standards but are increasingly being incorporated into big data and population-health management. On the other hand, unintended consequences may flow from what a clinical ethicist calls EHR quality and documentation pitfalls. Most vendors provide software with a variety of options for each assessment parameter e.
Yet, well-intended but clinically inappropriate IT decisions may be made. When clinicians identify problems, such as ambiguous yes or no options, they are encouraged to correct them by explaining clinical and legal consequences of such decision-making to IT department staff or to healthcare system executives. Other technology issues may also need to be voiced to vendors. In the paragraphs below, we will first consider efficiency and EHR technology concerns. Then we will offer HIT and nursing practice recommendation. Several studies have documented the lack of efficiency in current EHR documentation practice.
Activities that interrupted documentation included: phone calls, patient requests, and frequent transitions between various types of documentation modalities. Researchers suggested that physicians rely on synthesis rather than composition to write progress notes. Newer technologies that support synthesis are exemplified by highlighting and thus capturing single words or phrases from the chart to construct a new note descriptive of the patient at the current point in time.
Research is needed to compare the quality of such charting and to determine if it is less vulnerable to fragmentation than current charting methods. This research needs to include study of the documentation by both direct care nurses and physicians. A recent hospital-based study by Englebright et al.cars.cleantechnica.com/map144.php
The researchers concluded that this newer method minimized or eliminated documentation that did not directly support patient care. These investigators recommended use of alternative options for recording non-patient-care-related information and use of EHR technology to help nurses document and communicate basic care elements. The Nursing Practice Committee of the Missouri Nurses Association is committed to efficiency in the provision of care.
These nurses recognize that efficiency, including efficient capture of meaningful data, helps to translate information and to communicate nursing-based knowledge to other members of the healthcare team, thus improving patient safety and care quality. Efficiency-related issues, if unaddressed, minimize electronic documentation. Given a choice between providing high quality care and quality documentation within an inefficient EHR system, it is safer to provide the care required and minimize documentation time than to compromise on care to be sure that documentation is complete.
Understanding and correcting the etiology of such documentation work-arounds, and all other work-arounds, is essential to improving the healthcare system Debono et al. Members of the Nursing Practice Committee have recommended that, if current systems are inefficient or suboptimal, the goal for nurses, IT staff, and institutional administrators should be to improve the system not work around it. Direct care nurses report that EHR issues also affect the quality of their charting. These include, when using some products, rigidity in the number of available options for entering nursing data; a lack of pertinent patient information presented in a readily accessible and comprehensible manner to support critical decision making; drawbacks associated with over-dependence on the checklist quality of nursing documentation; and the relatively little attention given to diagnostic-specific interventions and their evaluation.
Such issues lead to poor visibility, presentation, and possible incorrect use of clinical information that may compromise patient outcomes. Issues related to electronic charting, however, may not always be the fault of the EHR. Documentation, electronic or otherwise, reflects the critical thinking of the nurse and the quality of the nursing care itself. In other words, correct or solid human reasoning is needed to interpret data collected correctly, make appropriate clinical judgements, act upon them competently, and document clearly.
When such is lacking, the lack is evident in the documentation. In addition to it being a vehicle that facilitates big data research, the EHR may be used to facilitate the regular review of randomly selected records for documentation case reviews and quality improvement purposes. For example, a random review may reveal findings like those indicated in Table 2 , which illustrate that the EHR is not a substitute for incorrect thinking.
In fact a well-constructed EHR reflects, as Table 2 shows, lapses in adhering to nursing standards.
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Conversely, a well-constructed EHR also reflects accurately how nurses think assess , arrive at clinical judgments diagnose , identify outcomes, plan, intervene and evaluate care Lang, An EHR documents practice and reflects the quality of underlying direct care nurse thinking; it does not replace thinking or serve as its substitute but reflects adherence to or lapses in adherence to nursing standards. User case scenario: 68 year old female admitted to nursing unit with diagnosis of pneumonia and history of heart disease.
Patient denies pain but complains of increasing fatigue, cough and shortness of breath. The admitting RN documents the initiation of intake and output; daily weights; and vital signs; including pulse oximetry, four times daily.