Developing evidence-based tools from EHR data

Abstract

Early in our nursing school journey, we all faced the daunting task of learning how to document patient care. We learned that documentation is important for team communication and serves as a legal document if needed. Despite these important functions, documentation is often seen by nurses as a required, yet time-consuming, task that isn't generally a highly valued part of patient care. Nurses would much rather spend time with their patients. However, with the advent of the electronic health record (EHR), documentation has taken on a new meaning and holds extended value. Data, documented by the clinical team and retrieved electronically, provide the content for quality measurement and research. As more evidence-based assessment tools are translated into practice, nurse managers and their staff members are uniquely positioned to lead or join the effort to make a difference with nursing documentation and EHR design. We have an opportunity to leverage the daily task of documentation into an activity that yields valuable practice evidence, decision support, and communication tools. As an example, our research team is using nursing documentation to build decision support for an important and common process—discharge planning and care coordination. With our 20-year history of using EHR data to build decision support for discharge referral decision making, our story yields valuable insights and lessons learned for nurse managers looking to leverage the EHR to derive evidence-based tools and position nurses to make a difference through documentation.