The Effectiveness of Nursing Documentation: Influence of EHR for Quality Care

The electronic health record (EHR) is increasingly being deployed within health care organizations to improve the safety and quality of care. However, to achieve these goals, the EHR must be used by clinicians, and this remains a major challenge. Various factors appear to be associated with EHR
use. Maximization of the technical characteristics supporting the system such as speed and value-added functionalities such as order entry systems or automated reports have been documented with higher rates of EHR use. User-related characteristics as well as training are also believed to be important.

The integration of the EHR into clinical workflow must be taken into consideration in the early phases of planning in order to optimize the integration of the system into routine clinical use. Indeed, the need for a good fit between the EHR and routine clinical practice is recognized as essential and time efficiency is one of several factors that is
used to assess the quality of this integration.

Clinical documentation and access to reliable information are crucial facets of nursing decision-making in care practice

Development and evaluation of an electronic nursing documentation system

• Nurses and other caregivers aim to exchange information about patients and administrative activities with high quality standards such as precision, timeliness, concurrency, conciseness, comprehensiveness, organization, and confidentiality.
• Nursing documentation is defined as written evidence demonstrating that the nurse’s authorized and moral responsibilities were met in order for care to be assessed.
• Accurate and comprehensive documentation of nursing interventions is essential for several other reasons. It improves patients’ outcomes, increases the quality and safety of healthcare services, ensures practice accountability, and facilitates communication between various involved health care stakeholders.
• Accordingly, the nursing documentation framework needs to be standardized, reasonably organized, and structured to mirror the phases of the nursing process, i.e., the assessment, diagnosis, planning, implementation, and evaluation of patient conditions.
• Despite the importance of clinical documentation, currently, there are undesirable situations of care recordings and a lack of an appropriate framework for documenting nursing care.
• Writing a nursing report is a routine event that that should be performed several times during a nurse’s daily work, therefore, nurses spend about 37% of their entire working time writing reports. One-half of all nurses must stay at work for 1–2 h after the end of their shifts, mainly to complete nursing records.
• Manual writing has several drawbacks including wasted time, disruption in patient care, medical errors, endangering patients’ safety, fading and illegibility of the paperwork, high staff turnover rates, legal problems and other similar factors.
• Due to the fast developments in information technology, the health industry actively attempts to employ electronic medical records (EMRs) for clinical practice, research, education, and supervision purposes.
• The Nursing information system (NIS), as a module of EMR, control nursing care or services and manages the nursing activities through which data are assembled, exchanged, stored, extracted, presented, and transferred
• It has been revealed that employing an EMR and electronic clinical nursing documentation leads to higher quality, more complete, and more patient-centric documentation than manual nursing documentation.

Effectiveness of the EHRs to Health Care Outcomes

Quality of Patient Care

• Facilitate planning and continuity of care
• Enhance patient safety and reduction of medical errors
• Reduce waiting times and delays in care
• Show progress of treatments for fast recovery and decrease length of hospital stay
• Address patient’s complex needs

Patient Engagement

• Facilitate patient’s understanding of medical records and information
• Improve relationship with health care professionals
• Enhance compliance to medications and treatments
• Encourage awareness and proper self-care
• Assist in understanding information which facilitate informed consent and medical decisions

Support Team-Based Care

• Help coordinate patient care
• Afford joint clinical decisions based on shared data
• Allow flexibility in multidisciplinary collaboration (e.g., managing referrals)
• Improve efficiency and quality of documentation among care Providers
• Enhance communication between health professionals

Managing Workload

• Ensure efficiency of clinical processes
• Lessen mental workload and burnout
• Reduce repetitive work
• Limit cost and resources for health care
• Save time and reduce the necessity for face-to-face communication

Data Liquidity

• Enhance access and retrieval of data
• Provide central system and storage of data
• Allow data analyses and compare trends of data for research purposes
• Ensure privacy and security of data
• Facilitate regulatory compliance

Benefits of electronic medical records:

Improved efficiency:

EMRs allow for quicker documentation, which can benefit patients needing rapid treatment. For example, an EKG can be performed and uploaded to a record in real-time, and a specialist can pull it up and advise within minutes. This leads to improved patient care outcomes as delays are shortened.

Standardization:

EMRs promote standard record-keeping to include staff and physician notes, assessment findings, and ordering processes.

Improved accessibility:

EMRs allow members of the healthcare team to access pertinent parts of the medical record easily. Also, records can effortlessly be retrieved- sometimes between different healthcare organizations.

Reduction of errors:

This is probably the most significant benefit of electronic medical records. Computerized physician ordering has helped reduce errors related to misinterpreted handwriting and transcription errors. EMRs often have flags or hard stops if an order is entered incorrectly (i.e., the wrong dose ordered, or a med ordered that is listed as an allergy).

Electronic medication administration is developed to assist staff in the rights of medication administration. Barcode scanning, for example, helps correctly identify the right patient, right time, and the right med. Additionally, abnormal test results are flagged to prevent them from being overlooked. EMRs also help to avoid any significant component of healthcare delivery to be missed.

Improved privacy and security for patients:

The more hands that touch paper records, the more at-risk private health information is. Paper charts sent to chart rooms or outside a facility is more at risk of a privacy breach. EMRs have safeguards in place to prevent violations. Access to certain parts of the medical record is given only to the appropriate employees. Flags are set up if a record is inappropriately accessed.

Improved efficiency:

EMRs allow for quicker documentation, which can benefit patients needing rapid treatment. For example, an EKG can be performed and uploaded to a record in real-time, and a specialist can pull it up and advise within minutes. This leads to improved patient care outcomes as delays are shortened.

Drawbacks to Electronic Health Records

Reduced oversight:

Sometimes it’s easy to click a button or enter shortcuts to reduce charting time. However, the mechanical nature of electronic charting can lead to an oversight of clinical findings. For example, assessment documentation shortcuts may default to “normal” findings, and the provider must alter based on an exam. If one component is overlooked, it’s false documentation. Frequent, repetitive documentation places the provider at risk, especially if feeling rushed.

Expensive to Implement:

Electronic medical record programs are expensive-in the millions. Organizations must purchase the software and train hundreds of staff in its use.

Technical malfunctions:

Any healthcare worker can attest to the crippling effect of technical difficulties with EMRs. When the system goes down, it’s like the apocalypse. Backup paper records must be kept, and data inputted later when the system is back up and running. Confusion as to what to do when this occurs can lead to patient care delays and potential errors. Healthcare organizations should have clear guidelines as to what to do when this happens, and paper record-keeping available and accessible.

Over-standardization:

Healthcare providers can attest to this fact as well. It’s frustrating for providers when they need to order something that has not been inputted into the system. Lesser-used medications or treatments may not be part of the selection process, which leads to workarounds that can create frustration, confusion and potential errors.

Less patient interaction:

This is a significant complaint among both patients and providers. Patients see their healthcare provider staring at a computer screen more than they lay eyes on them, which leads to a perception of de-personalization in care. Providers often feel that they spend more time documenting than caring for patients.

Increased virtual work:

To piggyback on the point above, providers may argue that their workload has increased with the advent of EMRs. Completing charts, fielding test results that pour in throughout the day/ shift, and even handling patient emails can bog down providers immensely. While the ability to communicate with your provider is a huge benefit for patients, it creates an enormous amount of added work for providers.

REFERENCES

1. Ferdousi R, Arab-Zozani M, Tahamtan I, Rezaei-Hachesu P, Dehghani M. Attitudes of nurses towards clinical information systems: a systematic review and meta-analysis. Int Nurs Rev. 2021;68(1):59 66. 
2. Association AN. ANA’s principles for nursing documentation: guidance for registered nurses. ANA, Nursebook: Silver Spring, MD; 2010.
3. Groot K, Sneep EB, Paans W, Francke AL. Patient participation in electronic nursing documentation: an interview study among community nurses. BMC Nurs. 2021;20(1):1–10.
4. Heidarizadeh K, Rassouli M, Manoochehri H, Tafreshi MZ, Ghorbanpour RK. Nurses’ perception of challenges in the use of an electronic nursing documentation system. CIN: Comput, Inform, Nurs. 2017;35(11):599–605.
5. What Are Some Pros and Cons of Using Electronic Charting (EMR)? https://www.registerednursing.org/articles/pros-cons-using-electronic-charting/

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