The Issue:

            Since the new age of technology, there have been so many advances in so many different job fields, the medical field being one of the most advanced. From new machinery to the electronic health record, there have been so many improvements to make the Registered Nurse’s job so much easier and more efficient. The electronic health record is a documentation tool for nurses to properly record on their patient assessment, evaluating care quality, improve patient safety, and maximize patient outcomes. (Lavin et al, 2015) However, nurses have determined many issues within their documentation and record keeping on the electronic health record, that they believe, make it very difficult to do their job at times. In a literature search completed by Prideaux, there seems to be a few issues that so many RNs are having with documenting on a computer system as opposed to paper charting. First, in general it looks as if poor quality record keeping is a recurrent problem within the hospitals. Even with auditing charting being a requirement, there are still problems completing a chart to its entirety. According to some nurses, they put less emphasis on their documentation and more on their direct patient care, not realizing they missed an area in their computer charting because there are so many different tabs to click. (2011). Anecdotal evidence conducted in a literature review by Blair and Smith also suggests that nurses see documentation as a time constraint along with an ignorance when it comes to the computer system. Charting is often left until last because of problems at the bedside, meaning nurses are charting quickly and inefficiently. (2012).

            While there are so many issues with documentation in general, paper or computer, The Journal of Nursing Scholarships attempted to examine what the issues were with electronic charting specifically. Much frustration was found within the nurses because they had difficulty to find an available computer, recalling a password, as well as a slow speed or freezing of the computer. (Kelley et al, 2011). Furthermore, computers are often located in the patients’ rooms which means when a nurse is in a room, completing an admission for example, they must go back and forth from talking to the patient and typing on their computer. It can often take away that personal connection that they are attempting to have. Nurses are taken away from the bedside for longer periods of time because they must concentrate on their computer charting as well as attend to any technological difficulties they may be having. When the computers are not working effectively, it creates much more stress than necessary.

Proposed Solution:

            There are so many different things that can be done in order to improve the quality of nurses’ documentation utilizing the computer system. First and foremost, education is the number one thing that must be completed in order to ensure that the nurses that will be using the computer system are competent enough to understand what they need to be documenting for each individual patient. If the nurse is unsure of all the areas they must be charting on, they are much more likely to miss something and therefore, the chart will not be seen as complete, effecting the hospital. It is extremely important for these nurses to show their competency for computer charting. If they are not competent, further education should be provided until both the nurse and the educator are satisfied with their process of documentation.

            Once nurses are signed off that they show the proper competency it takes to complete a chart on the computer, they should be held to that standard until the following year where they must show their competency once again. The next issue that can propose an easy solution would be having computers in the patients’ room. The light keeps them from being able to get a good night’s rest, and it takes away from that personal connection the nurse might be looking to have. In order to fix this issue, computers should be taken out of patients’ rooms and the hospitals should invest in workplaces on wheels (WOWs) so that nurses are able to claim their WOW at the beginning of the shift, and use it as their workstation for the shift. This will improve patient satisfaction as well as the nurses. They will have their own little area that they could possible keep medications on (if locked up) and keep their belongings in a place they know where to find when necessary. This will also decrease the issue of a nurse not being able to find an available computer to chart on later in the shift. One of the only issues that could occur with one computer being used for all patients would be for patients on some sort of isolation. Education must be provided to ensure that nurses do not take these computers into the isolation rooms and that they are wiped down with cleaner when necessary.

            In order to ensure that poor quality charting is a thing of the past, it will be important to establish some sort of committee to audit the charting before it is too late. Maybe if a there was a committee of nurses to look at the other nurses’ charting, less errors would occur because they would understand how to help each other more effectively. Also, the charting would not get too far where the primary nurse would not be able to fix their mistake. It is also important for communication to come into play with nurses and the technology department of the hospital. Very often, there are outside vendors that take care of major issues with the computers. When the nurse is frustrated because the computer keeps freezing or is working at an extremely slow pace, it is essential that they communicate this with the technology department, because they may have no idea of these issues, and if not told, they will never get fixed. Also, because nurses are the ones working with the system most often, if they believe there are ways the technology can be changed or improved, they must also communicate those concerns. Occasionally, the outside vendors must shut down the computer system for a given time in order to update the system or another reason. To cause the least frustration possible for the nurses, communication is also essential for this. They should know when the best time to shut down the computer system would be, for example, during the least busy times so nurses are not confused as to what they should do without their computers. When the system is down, an efficient backup system should always be provided. The only other issue, recalling a password, should propose an easy solution. Nurses should be given the opportunity to create their own password, one that might mean something to them that would make it somewhat easy to remember. A security question can also be provided so that a nurse can answer the question to retrieve their forgotten password easily.

            While there are some issues within the electronic health record when it comes to charting, there are many things that nurses themselves as well as the other professionals can do in order to improve the issues at hand. If these issues are taken care of and everyone works together, there is no the electronic documentation can improve patient safety as well as enhance patient outcomes.

References:

1.     Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse: A Journal For The Australian Nursing Profession, 41(2), 160-168.

2.     Freudenheim, M. (2014). The Ups and Downs of Electronic Medical Records - The Digital Doctor. Nytimes.com. Retrieved 18 October 2016, from http://www.nytimes.com/2012/10/09/health/the-ups-and-downs-of-electronic-medical-records-the-digital-doctor.html

3.     Kelley, T. F., Brandon, D. H., & Docherty, S. L. (2011). Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care. Journal Of Nursing Scholarship, 43(2), 154-162. doi:10.1111/j.1547-5069.2011.01397.x

4.     Lavin, M. A., Harper, E., & Barr, N. (2015). Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings. Online Journal Of Issues In Nursing, 20(2), 6. doi:10.3912/OJIN.Vol20No02PPT03

5.     Petkovšek-Gregorin, R., & Skela-Savič, B. (2015). Nurses' perceptions and attitudes towards documentation in nursing. Obzornik Zdravstvene Nege, 49(2), 106-125. doi:10.14528/snr.2015.49.2.50

6.     Prideaux, A. (2011). Issues in nursing documentation and record-keeping practice. British Journal Of Nursing, 20(22), 1450-1454.