EHR Documentation

Abstract

The phenomenon of "data rich, information poor" in today's electronic health records (EHRs) is too often the reality for nursing. This article proposes the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care across the continuum. The principles consider the need to optimize nurses' documentation efficiency while contributing to knowledge generation. The nursing process must be supported by EHRs through integration of best care practices: seamless workflows that display the right tools, evidence-based content, and information at the right time for optimal clinical decision making. Design of EHR documentation must attain a balance that ensures the capture of nursing's impact on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes "death by data entry." In 2014, a group of diverse informatics leaders from practice, academia, and the vendor community formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our health care system moves toward reimbursement on the basis of quality outcomes and prevention, the value of nursing data in this business proposition will become a key differentiator for health care organizations' economic success.

Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record

“…2 During an average 12-hour shift, nurses spend an estimated 19 to 40% documenting patient care and record data in over 600 flowsheet rows. 3 4 5 6 7 8 One quarter of nurses declared the EHR as cumbersome and almost half stated time spent documenting was problematic. 9 Further, 90% of nurses included in one study stated that the EHR had a negative effect on nurse–patient communication and 94% disagreed that the EHR promotes communication between the nurse and other members of the health care team.…”

“…10 As a result, system workarounds were created, posing threats to patient safety. 10 11 Current EHRs are built to support data entry, not to guide the delivery of highly reliable evidence-based care, 3 4 10 11 12 Despite nurses being the predominate user of the EHR, nursing documentation is not housed in a singular location within the record, disrupting their ability to synthesize information and formulate plans of care. 8 To further challenge nurses, documentation expectations are expanding, conflicting with nurses' goals for more time interfacing with patients and integrating care which impacts patient engagement, satisfaction, and quality of care.…”

Toward a Central Repository for Sharing Nursing Informatics’ Best Practices

“…because each health care organization implements an EHR system without the ability to leverage lessons learned from organizations that have gone before them or access a "best practice" central repository that holds examples of data sets complete with clinical terms mapped to standardized terminologies such as clinical LOINC and SNOMED-CT" . 1 Building on prior work done by the Transforming Nursing Documentation Working Group 10, in 2015 the authors volunteered to explore the feasibility of creating a central repository for best practices in nursing informatics. In this report, we share what we discovered.…”

Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran

“…The documentation of nursing services is important for some other reasons. It facilitates communication and collaboration [ 5 ], organises the nursing care chain [ 6 ], smoothens decision making about patient care and safety, ensures professional accountability [ 7 ], and provides regulatory and observatory standards that facilitate evidence-based processes [ 8 ] [ 9 ]. Documentation likewise serves as a tool for research, qualitative assessment, and the provision of records for medical jurisprudence.…”