Electronic Nursing Documentation Research Articles

Factors Associated with the Timeliness of Electronic Nursing Documentation.

ObjectivesTo investigate the factors associated with the timeliness of electronic nursing documentation using the entry time on the Electronic Medical Record (EMR) system.MethodsAs a retrospective study, data were extracted from January 1 to February 28, 2014 from a hospital EMR system and a nurses’ personnel information system. The timeliness of instances of nursing documentation was categorized into ‘timely’ or ‘untimely’ according to whether the entry time was time-stamped within the working hours during each day, evening, or night shift. Factors associated with the timeliness of the electronic nursing documentation were included in the logistic regression models as nurse- and patient-associated factors.ResultsAmong 1,700,247 instances of electronic nursing documentation, 79.3% (n = 1,347,711) were completed within the working hours. Years of nursing experience, nursing shift, days of the week, patients’ age, and medical department had a statistically significant associated with the timeliness of nursing records. Nurses with experience of more than 1 year entered nursing records over 2 times more during their working hours than did less experienced nurses. During the evening and night shifts, nurses were 1.49 times and 9.19 times more likely to enter nursing documents in a timely manner, respectively, as compared to those in the day shift.ConclusionsNursing documentation was typically completed outside of working hours when a nurse had little experience, worked during the day shift or weekdays, and when tasks were unpredictable. This shows that new nurses need support to familiarize them with various tasks and the overall workflow.

Caregivers Time Utilization Before and After the Introduction of an Electronic Nursing Documentation System in a Residential Aged Care Facility

Background: Despite increasing research interest in caregivers’ interaction with technology, there has been no attempt to investigate how the introduction of an electronic nursing documentation system in a residential aged care facility may affect caregivers’ use of their time. Objective: To assess how caregivers use their time before and after the introduction of an electronic nursing documentation system in a residential aged care facility. Methods: An observational work sampling study was undertaken with caregivers at 2 months before, and at 3, 6, 12 and 23 months after the implementation of an electronic nursing documentation system. Results: During the first 12 months after implementation, the proportion of time spent by personal carers on documentation increased whereas the proportions on direct care and communication decreased. At 23 months, these proportions had returned to pre - implementation levels. The proportion of time spent by recreational activity officers on documentation increased, that on communication decreased and the proportion on direct care remained stable during the first 12 months after implementation. The proportion of time on documentation returned to the preimplementation level after 23 months. Changes in proportions of time on other activities were not directly associated with the introduction of the electronic system. Conclusion: Caregivers in residential aged care facility may take over a year to integrate and use an electronic nursing documentation system in their daily work. Organisations implementing such systems should acknowledge the level of resources and time needed for the workforce to fully absorb the system and integrate it into their daily residential aged care service delivery

Electronic Health Records and Interruptions: The Need for New Interruption Management Strategies

Background: Interruptions have been widely studied in the health care domain, yet the nature of work in healthcare is changing with the pervasive use of electronic health records (EHRs). It is unclear how interruptions are changing with the introduction of new technology. Method: This study examines the nature of interruptions experienced by emergency medicine physicians before and after the transition from a home grown EHR to a commercially available system with electronic nursing documentation and computerized physician order entry (CPOE) capabilities. A minute-by-minute paper-based observation template was utilized to record the type of tasks interrupted (patient room, computer, verbal communication or paper charts/labs) as well as who initiated the interruption. Results: There was a significant difference in the type of tasks performed between the preimplementation and post-implementation (go-live) phase. Physicians spent less time on paper-related tasks (p < 0.01) and more time on computer-related tasks (p < 0.01) in the go-live phase. With the shift in task composition, physicians experienced a significantly higher rate of interruptions of computer tasks (p = 0.05), and a significantly lower rate of interruptions to of paper-based tasks (p < 0.01). There were no significant differences in the source of the interruption between the two phases. Discussion: Given the shifts in the types of tasks interrupted after the implementation of a commercially available system with CPOE, it is important to develop new interruption coping strategies. These strategies might include interface design principles to facilitate interruption recovery, less disruptive tactics for the person initiating the interruption, and providing the physicians with training on test systems with realistic data prior to using the new system to care for patients. Conclusion: It was demonstrated that EHRs change the nature of interruptions experienced during the immediate go-live period. Going forward, exploring methods for mitigating harm associated with this change will be critical in preserving patient safety.

Abstract 266: Heparin Documentation Improvement to Safely Manage Heparin Infusions

Background: Documentation of intravenous (IV) heparin infusion dose/hold by nurses is a vital component in heparin infusion management. The barcode electronic medication administration system is used when administering and documenting medications but precludes the documentation of continuous IV infusion doses such as heparin. Aim: To increase documentation of IV Heparin Administration Documentation in the electronic nursing documentation system. Methods: We reviewed multiple adverse patient events that involved heparin infusions. When discussing these events, we identified a common trend regarding the inability for nurses to document heparin IV doses/holds in the nursing electronic documentation. Although heparin volume infusion is charted every 4 hours, this does not reflect the exact heparin dose that the patient received when factoring heparin hold orders and boluses. With the involvement of clinical informatics, physicians, nurses, and a quality consultant (QC), we developed a method for nurses to document heparin IV doses and holds via the electronic documentation (Figure 1). On October 30 th 2012, two Cardiovascular Step-Down (CVSD) units championed the heparin process improvement documentation. The nurses on these units receive targeted education about the process improvement change. Audits were performed daily during the first month of implementation and periodically by the QC. Electronic communication was also sent out throughout VUH regarding the changes in heparin documentation. Results: Documentation of administered dose increased from 46% to 71% across VUH regardless of the type or level of education to the change. CVSD: Pre / Post n = 16/21 DOSE: 37.5% / 81% Both DOSE & VOLUME: 31.3% / 71.4% HOLD: 75% / 81% Drop Down: 43% use (68.8% annotation) Non ICU Control: Pre / Post n = 12 / 17 DOSE: 16.7% / 41.2% BOTH DOSE & VOLUME: 8.3% / 11.8% HOLD: 50% / 41.2% Drop Down: 11.1% use (88.9% annotation) ICU units were 100% in dose documentation post changes Conclusion: The heparin documentation change has increased the accuracy of the documentation of heparin dose, volume, and hold across VUH. Targeted education has the potential to increase compliance and adoption. The heparin dose documentation is now exported to an electronic heparin dashboard that physicians/providers can easily access.

Incorporating standardized nursing languages into an electronic nursing documentation system in Korea: a pilot study.

The purposes of this study were to (a) develop and implement a standardized nursing languages-based electronic nursing documentation system in Korea, and (b) explore nurses' experience with NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification languages in relation to nursing workflow. The system was developed by the research team and implemented in a tertiary hospital in Korea. Ten nurses used the system and interviews were conducted to explore nurses' experiences with the standardized nursing languages. The most frequently used NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification were identified. Nurses' experiences with standardized nursing languages and how they impact nursing workflow were analyzed. Obtaining valid and comparable data from this system will be critical in improving patient safety, quality, and evidence-based practice.

Staff experiences within the implementation of computer-based nursing records in residential aged care facilities: a systematic review and synthesis of qualitative research.

BackgroundSince the introduction of electronic nursing documentation systems, its implementation in recent years has increased rapidly in Germany. The objectives of such systems are to save time, to improve information handling and to improve quality. To integrate IT in the daily working processes, the employee is the pivotal element. Therefore it is important to understand nurses’ experience with IT implementation. At present the literature shows a lack of understanding exploring staff experiences within the implementation process.MethodsA systematic review and meta-ethnographic synthesis of primary studies using qualitative methods was conducted in PubMed, CINAHL, and Cochrane. It adheres to the principles of the PRISMA statement. The studies were original, peer-reviewed articles from 2000 to 2013, focusing on computer-based nursing documentation in Residential Aged Care Facilities.ResultsThe use of IT requires a different form of information processing. Some experience this new form of information processing as a benefit while others do not. The latter find it more difficult to enter data and this result in poor clinical documentation. Improvement in the quality of residents’ records leads to an overall improvement in the quality of care. However, if the quality of those records is poor, some residents do not receive the necessary care. Furthermore, the length of time necessary to complete the documentation is a prominent theme within that process. Those who are more efficient with the electronic documentation demonstrate improved time management. For those who are less efficient with electronic documentation the information processing is perceived as time consuming. Normally, it is possible to experience benefits when using IT, but this depends on either promoting or hindering factors, e.g. ease of use and ability to use it, equipment availability and technical functionality, as well as attitude.ConclusionsIn summary, the findings showed that members of staff experience IT as a benefit when it simplifies their daily working routines and as a burden when it complicates their working processes. Whether IT complicates or simplifies their routines depends on influencing factors. The line between benefit and burden is semipermeable. The experiences differ according to duties and responsibilities.

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Effects on the Quality of the Nursing Care Process Through an Educational Program and the Use of Electronic Nursing Documentation

To evaluate the effect of the educational program "Guided Clinical Reasoning" (GCR) and the introduction of an intelligent electronic nursing documentation system (e-doc) on the quality of the nursing process. Evaluation was conducted at three measurement points and rated with the instrument "Quality of Nursing Diagnoses, Interventions and Outcomes" (Q-DIO). GCR showed the best Q-DIO-scores. No long-term effect was found after GCR cessation. The e-doc delivered the lowest scores, while showing adequate support in using nursing diagnoses. E-docs can support conducting the nursing process, but for meaningful e-doc use, clinical reasoning is essential. High-quality nursing documentation requires recognition of factors obstructing or supporting nurses in the use of e-docs while conducting the nursing process.

Relationship Between Nursing Documentation and Patients' Mortality

Nurses alter their monitoring behavior as a patient's clinical condition deteriorates, often detecting and documenting subtle changes before physiological trends are apparent. It was hypothesized that a nurse's behavior of recording optional documentation (beyond what is required) reflects concern about a patient's status and that mining data from patients' electronic health records for the presence of these features could help predict patients' mortality. Data-mining methods were used to analyze electronic nursing documentation from a 15-month period at a large, urban academic medical center. Mortality rates and the frequency of vital sign measurements (beyond required) and optional nursing comment documentation were analyzed for a random set of patients and patients who experienced a cardiac arrest during their hospitalization. Patients were stratified by age-adjusted Charlson comorbidity index. A total of 15,000 acute care patients and 145 cardiac arrest patients were studied. Patients who died had a mean of 0.9 to 1.5 more optional comments and 6.1 to 10 more vital signs documented within 48 hours than did patients who survived. A higher frequency of comment and vital sign documentation was also associated with a higher likelihood of cardiac arrest. Of patients who had a cardiac arrest, those with more documented comments were more likely to die. For the first time, nursing documentation patterns have been linked to patients' mortality. Findings were consistent with the hypothesis that some features of nursing documentation within electronic health records can be used to predict mortality. With future work, these associations could be used in real time to establish a threshold of concern indicating a risk for deterioration in a patient's condition.

Morbidity, mortality, and improvement (MM&I) conference leading to change.

94 Background: During quarterly MM&I Conferences, a recurrent systems problem identified was the underreporting of chemotherapy infusion reactions. Attendees acknowledged difficulty in obtaining accurate data regarding adverse events and justifications for treatment cessation, which may lead to under dosing of effective therapies. Methods: MM&I conference is an interactive multidisciplinary forum that emphasizes discussion to improve system-based problems. Attendees include faculty, fellows, residents, nursing staff, informatics and pharmacy representatives. Participants used the Ickwaka Fishbone Diagram to identify issues that led to underreporting of reactions. Through discussion of the issues and identification of potential improvement activities, participants recognized that improved nursing documentation could accurately capture data related to adverse drug events. Representatives from the informatics department identified a report that could be generated automatically when infusions are stopped that would require nursing staff to identify the type of reaction and give justification for not completing the infusion. Reports would also include actions taken and patient responses. Results: Implementation of electronic nursing documentation revealed that the prevalence of infusion reactions were much higher than previously identified. During the first 6 months of electronic documentation there were 71 identified reactions compared to 46 reactions documented during the 6 months prior to implementation. Paclitaxel (22%) and Rituximab (39%) were identified as the two most common agents associated with infusion reactions. Twenty (28%) infusion reactions resulted in cessation of that particular chemotherapy. Conclusions: The format of the MM&I Conference engaged members of a multidisciplinary team to promote collaboration for system-based improvements in patient care and safety. Electronic nursing documentation has put a mechanism in place to capture data related to infusion reactions that will allow us to evaluate the effectiveness of future interventions to decrease the prevalence of infusion reactions, as well as the number of therapies that are stopped indefinitely due to these reactions.

Evaluation of the nursing process and use of an electronic documentation in an acute hospital in Switzerland

Research questions The main purpose of this study was to evaluate the impact of the educational program Guided Clinical Reasoning (GCR) on the quality of nursing documentation in an acute hospital in Switzerland. Additionally the effect of the introduction of an intelligent electronic nursing documentation expert system (e-doc) and simultaneous cessation of GCR were examined in 2011. Methods To evaluate the impact of GCR a cross-sectional evaluation study was conducted at three measurement points in the years 2005, 2006 and 2011. Each sample of 36 documentations was rated by the instrument “Quality of Nursing Diagnoses, Interventions and Outcomes” (Q-DIO) and the results compared with a quantitative design. To study the effects of the e-doc a descriptive design was used. The amount of chosen nursing diagnoses and their degree of content accuracy was analyzed for both nurses and the electronic documentation system. Furthermore the level of correct “decision support” in hypothetical nursing diagnosis by the e-doc and the use of this offer by nurses were contrasted. Findings The GCR program showed the best effects regarding the quality of the nursing process in 2006. Despite implementing an intelligent e-doc system as decision support tool, measurement point three (2011) proved the lowest scores, except for phrasing accurate nursing diagnoses. The quality of documentation regressed to the level of 2005, one year after implementing nursing diagnostics. The skills for using the NNN (NANDA, NIC, NOC) nursing process accurately, acquired in 2006, did not sustain. While nurses wrote detailed reports, they used a limited amount of recurring diagnoses. In comparison e-doc consistently and abundantly provided correct hypothetical nursing diagnoses. Despite this support they were scantly used by nurses. Conclusions Being at close temporal proximity the first two measurement points provided constant training for nurses in GRC and a high documentation quality was achieved. To accurately depict the nursing process, an electronic support system alone did not suffice, particularly as the GCR program was terminated. Electronic support systems can assist in conducting a theory-based nursing process, but clinical reasoning is essential for a meaningful use of e-docs. Constant support of nurses and awareness of barriers in conducting the nursing process and using intelligent decision supporting tools are crucial for a high level of quality in nursing documentation.

The impact of an electronic nursing documentation system on efficiency of documentation by caregivers in a residential aged care facility

To examine the effect of the introduction of an electronic nursing documentation system on the efficiency of documentation in a residential aged care facility. Modern technology has the potential to free caregivers in residential aged care facilities from their burden of paper documentation and allow them more time to care for residents. To date, there is inadequate evidence to verify this assumption. Longitudinal cohort study with work sampling method for data collection. This study was conducted between 2009-2011; two months before and 3, 6, 12 and 23 months after implementation of an electronic documentation system. A work classification tool was used by an observer to record documentation activities being performed on paper or on a computer by the caregivers. When compared with the proportion of time caregivers spent on documentation in the preimplementation period, personal carers' proportion reduced at three months after implementation. The proportion increased from six months and then dropped at 23 months. Recreational activity officers' proportion increased at three months after implementation. It stabilised at six months and increased again at 12 months. At 23 months, the proportion returned to the preimplementation level. Less than half of the caregivers' time on documentation after implementation was associated with computer-related tasks. Introduction of an electronic documentation system may not necessarily lead to efficiency in documentation for the caregivers. Charting some information items on paper and others on a computer may hinder realization of documentation efficiency. To optimise the efficiency benefit of electronic documentation in a residential aged care facility, it is not only necessary to automate all nursing forms but also to ensure that the system is aligned with caregivers' documentation practice. Continuous education and mentor support is essential to ensure caregivers' effective usage of the electronic system.

Evaluation of the national nursing model and four nursing documentation systems in Finland – Lessons learned and directions for the future

ObjectivesTo evaluate the feasibility of the national nursing model and usability of four widely used nursing documentation systems and to study their usefulness in multi-professional collaboration and information exchange. MethodsQualitative usability study methods were used, including the use of scenario walkthroughs, contextual inquiries, thematic interviews and inspection-based expert reviews in the users’ clinical contexts. ResultsThe nursing process model was shown to be feasible in nursing practice but the national nursing classification was considered too detailed, multi-layered and difficult to use and understand. The four evaluated nursing documentation systems had many usability problems which resulted in them being difficult to use and produced extra documentation workload. Generally, electronic nursing documentation improves patients’ and health professionals’ legal protection and makes nursing care more transparent; however, the documentation systems did not provide good support for multi-professional care and information exchange. ConclusionsNursing models should comply better with nursing practices and support nurses in patient care and interventions. An essential improvement in practice would be the use of specific templates that are easy to apply in specific situations with homogeneous patient groups. Collaborative care aspects and better utilization of information require that the nursing model is designed to support not just documentation but also information utilization.

Barriers and facilitators to the use of computer-based intensive insulin therapy

Purpose Computerized clinical decision support systems (CDSSs) for intensive insulin therapy (IIT) are increasingly common. However, recent studies question IIT's safety and mortality benefit. Researchers have identified factors influencing IIT performance, but little is known about how workflow affects computer-based IIT. We used ethnographic methods to evaluate IIT CDSS with respect to other clinical information systems and care processes. Methods We conducted direct observation of and unstructured interviews with nurses using IIT CDSS in the surgical and trauma intensive care units at an academic medical center. We observed 49 h of intensive care unit workflow including 49 instances of nurses using IIT CDSS embedded in a provider order entry system. Observations focused on the interaction of people, process, and technology. By analyzing qualitative field note data through an inductive approach, we identified barriers and facilitators to IIT CDSS use. Results Barriers included (1) workload tradeoffs between computer system use and direct patient care, especially related to electronic nursing documentation, (2) lack of IIT CDSS protocol reminders, (3) inaccurate user interface design assumptions, and (4) potential for error in operating medical devices. Facilitators included (1) nurse trust in IIT CDSS combined with clinical judgment, (2) nurse resilience, and (3) paper serving as an intermediary between patient bedside and IIT CDSS. Conclusion This analysis revealed sociotechnical interactions affecting IIT CDSS that previous studies have not addressed. These issues may influence protocol performance at other institutions. Findings have implications for IIT CDSS user interface design and alerts, and may contribute to nascent general CDSS theory.

Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff?

Purpose To determine whether the introduction of an electronic nursing documentation system in a nursing home reduces the proportion of time nursing staff spend on documentation, and to use this information in evaluating the usefulness of the system in improving the work of nursing staff. Methods An observational work sampling study was conducted in 2009 and 2010, 2 months before, and 3, 6 and 12 months after the introduction of an electronic nursing documentation system. An observer (ENM) used a work classification tool to record documentation activities being performed using paper and with a computer by nursing staff at particular times for periods of 5 days. Results Three hundred and eighty three (383) activities were recorded before implementation of the electronic system, 472 activities at 3 months, 502 at 6 months, and 338 at 12 months after implementation. There was no significant difference between the proportion of time nursing staff spent on documentation 2 months before and 3 months after the implementation of the electronic system. Six months after implementation, the proportion of time on documentation increased significantly and after 12 months, settled back to original levels that were recorded in the paper-based system. Over half of the proportion of time on documentation at 6 and 12 months after implementation was spent on paper documentation tasks. Conclusion Introduction of an electronic nursing documentation system did not reduce the proportion of time nursing staff spent on documentation. This may in part have been a result of the practice of documenting some information items on paper and others on a computer. To reduce the use of paper documentation or to achieve a paper-free documentation environment in this setting, an in-depth understanding of nursing staff's information needs, and documentation workflow is necessary.

Contextual inquiry method for user-centred clinical IT system design.

Little can be found in the literature about the applicability of field study methods, particularly contextual inquiry, in the health informatics field. This paper aims to inform and promote the use of contextual inquiry for user-oriented design of clinical information technology (IT) systems. The paper describes how the method was applied in two empirical studies to gather data about end-users' needs, as well as the use and usability of dictation solutions and electronic nursing documentation systems from the viewpoint of their end-users' in real working surroundings. Experience indicates that, compared to typical usability evaluation methods, contextual inquiry may provide valuable support for user-centred design activities: the method is suitable for increasing researchers' understanding of clinical practices, contexts of work, and end-users' interaction with numerous IT systems. However, in clinical settings there are special challenges related to recording and privacy issues, a wide variety of clinical practices and contexts of technology usage, as well as the hectic nature of clinical work.

Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care

Electronic health records are expected to improve the quality of care provided to hospitalized patients. For nurses, use of electronic documentation sources becomes highly relevant because this is where they obtain the majority of necessary patient information. An integrative review of the literature examined the relationship between electronic nursing documentation and the quality of care provided to hospitalized patients. Donabedian's quality framework was used to organize empirical literature for review. To date, the use of electronic nursing documentation to improve patient outcomes remains unclear. Future research should investigate the day-to-day interactions between nurses and electronic nursing documentation for the provision of quality care to hospitalized patients. The majority of U.S. hospital care units currently use paper-based nursing documentation to exchange patient information for quality care. However, by 2014, all U.S. hospitals are expected to use electronic nursing documentation on patient care units, with the anticipated benefit of improved quality. However, the extent to which electronic nursing documentation improves the quality of care to hospitalized patients remains unknown, in part due to the lack of effective comparisons with paper-based nursing documentation.

Nursing Satisfaction and Attitudes With Computerized Software Implementation

In late 2006, a 340-bed, not-for-profit, tertiary-care medical center implemented an electronic nursing inpatient documentation system. The computerized software replaced the paper nursing documentation system and was intended to efficiently capture inpatient healthcare information at the point of care. Preimplementation and postimplementation surveys were administered to evaluate nursing staff attitudes and satisfaction levels and their reactions to computers and the system implementation. A modified Stronge-Brodt Nurses' Attitudes Toward Computers questionnaire was used for this quasi-experimental study that included a convenience sample of nurses from seven different nursing units. Attitudes were measured using the Nurses' Attitudes Toward Computers questionnaire, and satisfaction was measured using a researcher-developed visual analog scale. Findings included decreased overall satisfaction with and a decrease in positive attitudes toward computerization from the presurvey through postsurvey. Recommendations for future studies and successful electronic medical record implementation were identified.

Agreement between common goals discussed and documented in the ICU

Meaningful use of electronic health records (EHRs) is dependent on accurate clinical documentation. Documenting common goals in the intensive care unit (ICU), such as sedation and ventilator management plans, may increase collaboration and decrease patient length of stay. This study analyzed the degree to which goals stated were present in the EHR. Descriptive correlational study of common goals verbally stated during daily ICU interdisciplinary rounds compared with the presence of those goals, and actions related to those goals, documented in the EHR over the subsequent 24 h for 28 patients over 15 days. The study setting was a neurovascular ICU with a fully implemented electronic nursing and physician documentation system. Descriptive statistics and χ(2) analyses were used to assess differences in EHR documentation of stated goals and goal-related actions. Inter-coder reliability was performed on 16 (13%) of the 127 stated goals. One-quarter of the stated goals were not documented in the EHR. If a goal was not documented, actions related to that goal were 60% less likely to be documented. The attending physician note contained 81% of the stated ventilator weaning goals, but only 49% of the sedation weaning goals; additionally, sedation goals were not part of the structured nursing documentation. Inter-coder reliability (κ) was greater than 0.82. Observations in a single ICU setting at a large academic medical center using a commercial EHR. The current documentation tools available in EHRs may not be sufficient to capture common goals of ICU patient care.

Entwicklung und Implementierung der elektronischen Pflegedokumentation der Solothurner Spitäler AG: eine Erfolgsstory!?

Summary The project ‘Developmen ta nd Implementation of an Electroni cN ursin gD ocumentation’ started in the year 2006 by order of the hospital boar df or developing ,t esting and subsequent productive implementation of an electronic car ed ocumentation system. Du et ot he guidelines provided and an analysis of available software tools the soH AG decided to develop an ew software application. This article describes th es teps in the development and implementatio no ft he electronic nursing documentation ePD .I na ddition, ap art of the evaluation of the productive implementatio ni sp resented.