You are caring for five patients on a busy, 28-bed neurological medical-surgical unit, which recently transitioned to all electronic documentation and healthcare computerized provider order entry (CPOE). There is no longer any bedside paperwork.

All of your staff members have completed the required training and you have been assigned as expert lead for any questions that may arise during your shift. The expectation is that all nurses and clinical staff will document all care delivery in the bedside computers located in each patient\’s room or via the workstation on wheels (WOW).

However, you have noticed a trend with experienced nurses spending extra time at the end of their shifts (30 or more minutes) documenting the nursing care provided during the shift. The expectation is that they should be documenting care delivery as soon as it is complete rather than at the end of their shifts.  Nursing Documentation in the Electronic Age Essay Paper

Answer the following questions based on the information provided:

Explain how you would address the concern with the delay in nursing documentation with your team.
Do you see the transition to all electronic documentation as having a positive or negative effect on patient-centered care? Support your answer with evidence from the literature.
Explore the role of advancement in information technology and its effect in patient care. Does more technology use improve time with patients? Use at least two sources to support your response.
For additional details, please refer to the Case Study Guidelines and Rubric document.
You will examine two case studies in this course. These assignments will help apply your theoretical learning to real-world scenarios. Within each paper, be sure
to address each question in the given prompt thoroughly and include the following elements:
1. A thorough response to all parts of the prompt
2. An assessment of the role of patient care technologies
3. Incorporation of sources to support your response
Guidelines for Submission: Case study papers should be 2–3 pages in length with double spacing, one-inch margins, and 12-point font. Each case scenario should
include at least two peer-reviewed sources. APA formatting is to be used for references and in-text citations.
Critical Elements Exemplary (100%) Proficient (88%) Needs Improvement (75%) Not Evident (0%) Value

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Case Study: Nursing Documentation in the Electronic Age

Explain how you would address the concern with the delay in nursing documentation with your team.

The nurses must be made to understand that documentation is an important aspect of nursing care delivery as it helps in tracking the steps taken and how the patient has responded to each step. Delayed documentation presents concerns as there is a possibility of some of the case details being forgotten or overlooked so that they are not recorded. Still, there are situations when delayed documentation becomes necessary, especially when providing lifesaving care in extreme emergency or triaging. Still a key principle in nursing documentation is that it must be timely, contemporaneous and sequential. This is important for supporting the ability of the health care team to make informed decisions and provide high quality care in continuity of a patient’s case. If the documentation is delayed, then it is likely to interfere with the ability of other medical personnel who are unfamiliar with the case or involved in the case to use the documentation (Grando, Rozenblum & Bates, 2015).

In addition, the nurses must be made to understand that timely, accurate, and complete documentation serves six other important functions. Firstly, it helps with efforts to improve performance and quality processes. It is a primary source of evidence that is applied to continuously measure performance outcomes against set standards. Secondly, it helps to support research activities by providing accurate information about care outcomes and patient characteristics. Evaluating and analyzing the information presented in documentation helps with identifying areas that can be targeted for quality improved and goals for evidence-based practice. Thirdly, the documentation is used to determine the severity of a patient’s illness, the intensity of nursing services provided, and the quality of care upon which to base the reimbursement and payment. Fourthly, it provides a method for evaluating and improving care quality and maintaining current care standards to act as evidence that legislative and regulatory goals and mandates are being met. Fifthly, they serve a legal function as evidence in legal cases. Delayed documentation is untimely and could be inaccurate and incomplete thereby resulting in undesirable legal outcomes to include risk of liability, jeopardizing legal defenses and claims, and impeding legal fact finding. Finally, it helps with credentialing by monitoring medical personnel for compliance with the standards that govern practice and determining which personnel to grant credentials within the organization. As such, the nurses must be made aware of the concerns presented by delayed documentation so that they appreciate the delivery of timely documentation (Lau & Kuziemsky, 2016).

Besides that, the nurses would be supported in improving efforts to provide timely documentation by introducing standardized abbreviations, symbols and codes. This would help in reducing the amount of time spent on documentation while improving communication and understanding between the medical personnel thereby leading to more effective and safe care for patients. This would require that the facility establish a list of approved abbreviations, symbols and codes, and monitor the documentation for appropriate use (Stanhope & Lancaster, 2020).

Do you see the transition to all electronic documentation as having a positive or negative effect on patient-centered care?

The transition to electronic documentation would have a positive effect on patient-centered care. In fact, it helps the medical personnel to better manage care provision for patients even as they provide better health care. Firstly, it helps to reduce the cost of health care by improving health, reducing duplication of services, improving safety and reducing paperwork. Secondly, it enables the medical personnel to improve their efficiency even as the facility meets its business goals. Thirdly, it helps to improve work-life balance and productivity for medical personnel (Atasoy, Greenwood & McCullough, 2019). Fourthly, it helps to enhance the security and privacy of patient data. Fifthly, it helps to promote accurate, complete and legible records that streamline billing and coding. Sixthly, it improves the communication and interaction between medical personnel and patients (Hoover, 2016). Seventhly, it helps to improve the provision of safe care, reducing medical errors and effectively diagnosing patients. Besides that, it helps with securely sharing information among authorized persons, enabling quick access to the information for efficient and coordinated care delivery, and providing complete, up-to-date and accurate information at the point of care (Jette & Kwon, 2019).

Explore the role of advancement in information technology and its effect in patient care. Does more technology use improve time with patients?

More technology use improves time with patients. In this case, advances in information technology would improve work flow efficiencies by reducing the amount of time spend pulling charts. In addition, they improve access to comprehensive case information, help with managing prescriptions, improve scheduling of appointments with patients, and provide remote access to patients’ information. This ensures that medical personnel and even patients are better informed about the case details so that they spend less time on information that is already known and more time on exploring the unknown case details. The advancements would allow patients and medical personnel to focus on the critical information needs based on the identified gaps (Wani & Malhotra, 2018). In addition, it allows medical personnel to spend less time on documentation thus freeing up more time to communicate with patients. Besides that, the advancements in information technologies improve communication with patients by leveraging personal health records and patients’ portals thereby more effectively engaging patients in managing their care even as they gain the capacity to interact with medical personnel from a more knowledgeable position (Manca, 2015). As a result, the more information technology use improves time with patients.

References

Atasoy, H., Greenwood, B., & McCullough, J. (2019). The Digitization of Patient Care: A Review of the Effects of Electronic Health Records on Health Care Quality and Utilization. Annual Review of Public Health, 40, 487-500. https://doi.org/10.1146/annurev-publhealth-040218-044206

Grando, M., Rozenblum, R., & Bates, D. (Eds.) (2015).  Information Technology for Patient Empowerment in Healthcare. De Gruyter.

Hoover, R. (2016). Benefits of using an electronic health record. Nursing, 46(7), 21-22. https://doi.org/10.1097/01.NURSE.0000484036.85939.06

Jette, N., & Kwon, C. (2019). Electronic Health Records—A System Only as Beneficial as Its Data. JAMA Network Open, 2(9), e1911679. https://doi.org/10.1001/jamanetworkopen.2019.11679

Lau, F. & Kuziemsky, C. (2016). Handbook of EHealth Evaluation: An Evidence-Based Approach. University of Victoria.

Manca, D. (2015). Do electronic medical records improve quality of care? Yes. Canadian Family Physician, 61(10), 846-847.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607324/

Stanhope, M., & Lancaster, J. (2020). Public Health Nursing: Population-Centered Health Care in the Community. Elsevier, Inc.

Wani, D., & Malhotra, M. (2018). Does the meaningful use of electronic health records improve patient outcomes? Journal of Operations Management, 60, 1-18. https://doi.org/10.1016/j.jom.2018.06.003  .  Nursing Documentation in the Electronic Age Essay Paper