Nursing documentation is a format that is used to communicate patient’s progress among interdisciplinary team members. Standardized clinical documentation in nursing remains complex. There is clinical evidence in literature associating delivery of nursing care to clinical documentation. Electronic documentation promotes accuracy, continuity of care and nurse patient interaction. Health care facilities have invested greatly in electronic health record to maximize reimbursement and benefit from grant and other incentives. In the near future, Nurses must become computer literate to remain competitive and competent. The profession will significantly change with the adoption of electronic documentation in healthcare worldwide. There will be an increase demand for electronic gadgets with advanced technical features.
Informatics has been around since the early 1800 with Herman Hollerith who invented the Tabulating Machine. Health informatics started evolving in the 1950 with the integration of computer in health care. This new method is progressively replacing paper charting which is often cumbersome, hard to read, time consuming and difficult to archive for an extended period of time. Paper or manual documentation has been the accepted format for many years in nursing, and baby boomers nurses are very comfortable with paper charting. With the evolution of electronic documentation, the Center for Medicaid and Medicare-CMS requires health care facility to convert to Electronic Health Record (EHR) to maximize payment. The electronic system is very well promoted and accepted across the United States. In 2011, Institute Of Medicine (IOM) “strongly recommended the use of electronic solutions to improve quality of care provided to hospitalized patients” (Tiffany et al. 2011).
Clinical documentation is accessible to several team members simultaneously and is easy to store in the data base. Many clinicians believe that “ much of the national attention around the use of electronic solutions assumes that there is a potential for improved patient health outcomes” (p.155). With the adoption of clinical documentation, nurses will communicate more effectively with interdisciplinary team. In addition, the system will also promote nurse to patient rapport while collecting clinical data. Nurses no longer have to rely on human memory to obtain pertinent information during assessment to document in paper charting because electronic system contains approved nursing diagnosis and care plan options based on admitting diagnosis or clinical symptoms.
Millennial nurses are younger and very receptive to electronic record and “ nurses reported being able to complete their work quicker with electronic documentation than paper-based” (p.156) .The integration of electronic charting will enable nurse to perform on time charting at the bedside and improve patient nurse therapeutic relationship.
Following the implementation of Electronic Health Record in a Florida hospital, a doctoral student from the University of Miami and a PhD instructor conducted a pilot study on a medical surgical unit to evaluate quality of care using electronic versus paper-based documentation. In a 560 beds medical center, 139 patients record were reviewed and analyzed in comparison to manual charting. A descriptive study was completed ,and there was evidence that electronic documentation improves quality of care because “ nursing documentation has shifted from the written medical record to the electronic health record because use of the EHR is considered to be beneficial to the quality and safety of health care” ( Li, 2012). The study also established direct relationship between electronic documentation and communication among interdisciplinary team members. Furthermore, it also showed the ability to collect and analyze data and trends in nursing documentation for consistency. Overall, the author and his colleague found eleven out of one hundred thirty-nine documentation inconsistent and incomplete. Inclusion criteria was electronic documentation in nursing and the study was conducted in one setting. This was a limited study because documentation focused mainly on pressure ulcers in acute care.The author suggested further studies to evaluate the effectiveness of electronic documentation.Nursing is very broad and will require more complex studies to evaluate documentation in other nursing areas and specialties.
Implication for Practice
With the evolution of informatics in nursing, there are many opportunties for nurses to advance their knowledge in electronic data management systems. The Center for Medicare and Medicaid Services (CMS) encourages providers and health facility to adopt EHR to improve patient outcomes and care delivery. A former United States executive was very supportive of electronic health care record and “In an effort to support the development of IT systems in health care settings, President George W. Bush proposed that the fiscal year 2005 budget include $100 million for projects to test the effectiveness of using electronic health records in DSS” (O’Meara, 2007). This really validates the impact of electronic record on patient care and encourages health care professionals to be receptive to the new informatics trends.
Nurses will be expected to be proficient in technology and able to complete electronic documentation as established by healthcare facilities. Nurses ought to adapt to new informatics perspectives and comply with electronic record regulation. Clinical documentation will enable nurses to perform on time charting at patient’s bedside and access patient record remotely . Some nurses might be apprehensive to changes in the electronic documentation due to knowledge deficit in technology. Further clinical studies are deemed appropriate to evaluate the relationship between clinical documentation and patient outcomes. There should be more studies focusing on patient’s perception about clinical documentation and impact on delivery of nursing care. There should be studies analyzing the amount of time nurses spend to perform electronic charting each shift, and more studies should be conducted on nursing attitude toward electronic documentation. Finally, studies should be conducted across the country in different setting using mixed sample with different background.
Clinical informatics has changed nursing in many ways, and nurses are expected to be proficient in electronic data management to comply with the current trends. Paper-based documentation will soon become obsolete over electronic clinical documentation. Many facilities have invested millions of dollars to expand health care delivery and comply with federal recommendations in managing patient record. After thorough analysis of peer reviewed articles, it is evident that the integration of electronic documentation has directly impacted delivery of nursing care. Nurses are expected to complete training and acquire new knowledge about the new system and associated features. The costly investment is an incentive to higher reimbursement for services provided, and nursing trends will continue to exhibit the expansion of electronic clinical documentation to promote positive impact on patient outcome and satisfaction. Therefore, there is a significant need for nursing curriculum to incorporate informatics and technology in the program.