From Old to New: Process of Integrating PACU Phase 1 Documentation and Workflow from Old Electronic Health Record (EHR) System to New Electronic Health Record (EHR) System

Abstract

<h3>Background Information</h3> In 2019, a new Electronic Health Record (EHR) was implemented to standardize and streamline access of patient health records across the health care system. Meaningful use of EHR provides benefits such as safety, quality, and efficiency in patient-care delivery. The adoption of the new EHR system has created significant disruption in the complex workflow of busy units, as well as frustration to users specifically in the usability functions of the new EHR system. This project will outline strategies and processes to ensure that resources are equipped to handle its complexity by employing methods to assist user for seamless transition from an old EHR system to new EHR system in phase 1 PACU. <h3>Objectives of Project</h3> •Identify and create a framework of key elements to bridge the gap in nursing documentation •Provide educational tools focusing on the change in workflow and documentation of clinical pathways •Create an audit tool to address nursing documentation compliance <h3>Process of Implementation</h3> Identified super users to serve as unit resources. Staff training included mandatory learning modules, post-tests, and unlimited practice simulations. All PACU workflow and clinical pathways were reviewed and revised to ensure the necessary "must haves" were included in the new platform. Created tip sheets of new workflow processes. An audit tool was created to address nursing compliance issues and cover key elements of workflow and documentation of clinical pathways. Leveraged use of lean methodology through daily huddle discussion of issues and generating ideas. <h3>Statement of Successful Practice</h3> The goals of the EHR implementation were achieved by familiarizing users with the new system through education, hands-on training, and constant follow through via lean methodology. Success was measured by rate of resolution of issues which achieved 100% by February 2020. Completion rate of RN documentation audits exceeded the set goal by 12.4%. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Providing the appropriate education and hands-on training served as of great value for successful implementation. The tip sheets created by the team improved effectiveness of user workflow and was spread to several PACU facilities within the healthcare system & vendor for their education and training.