A Key Communication Tool

Nursing Communication And Documentation

Discuss about the Nursing Narrative Notes In Electronic Health Records:  A Key Communication Tool.

Quality professional communication in nursing is essential for desirable patient outcomes. Understanding the concepts and principles involved is as important as the application of the said principles in nursing practice. Nursing documentation is one of these concepts. In nursing, something not documented is considered not done. it is one of the traditions of nursing. It is ever important in this era of patient-centered care.

The current paper will critique the following topic that relates to professional nursing communication: narrative notes in the electronic health record: a key communication tool. It will offer a critical analysis of the concepts of electronic health records and the incorporation of narrative notes in the electronic records. The strengths and limitations of the concept will be dissected with a view of presenting clear recommendations and implications for nursing practice. The concepts will be discussed with current studies from peer-reviewed journals and publications.  Nursing Narrative Notes In Electronic Health Records Discussion Paper

The proper documentation of patient status is a skill that nurses use to effectively communicate the health status both current and past and the outcomes of continued care. Proper nursing documentation should show the nursing thinking process as decisions behind patient care are done and also provide the evidence of patient progress. Many pathways exist in this regard including clinical notes, narrative notes, focus notes and problem-oriented approaches (Blair & Smith, 2012). In the era of patient-centered care and medico-legal issues, nurses too have to be on the right side of the law to avoid litigation. This can be achieved through proper documentation of the entire patient care process.

A popular saying in the nursing field holds true; not documented, not done. it is a culture that has been fostered and has shown to improve patient outcomes and clinical progress. It also enhances interdisciplinary communication and flow of information. A good example is continuity of care following a handover of shifts (Kossman & Scheidenhelm, 2008).

A study by Keenan et al. (2012) showed nurses devoted 31 to 37% of their entire shift time documenting, communicating the information and retrieving it, with 7% of the time spent documenting. This is the reason an effective recording system was sought after, and electronic health records came to be widely used (Clynch & Kellett, 2015).

Electronic health records are one of the documentation methods currently being incorporated into the health sector (Hayrinen, Saranto, & Nykanen, 2008). The transition from paper-based medical recording to electronic was deemed a step-up in the right direction (Cheung et al., 2013). The electronic health system allowed for entry of patient data into the system that allowed retrieval and editing of data by different health professionals with access (Hayrinen, Saranto, & Nykanen, 2008). Singapore is one of the countries that has implemented this global trend in health recording. It was postulated that reduction in medical errors and enhancing effective communication through these systems should translate to better patient care.

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Electronic Health Records

Data in the health record are entered as a structured field with a provision for entry of narrative formats. This was implemented to reduce the time taken by clinicians accessing and charting paper records. Structured data fields in the electronic health record allowed for data to be entered faster, faster analysis and provided easier access, with menus that can be easily located by clinicians. The structured data can also be used for assessment and to guide recommendations since some fields can be marked as required or mandatory necessitating the clinician to follow protocol.

As mentioned earlier most electronic health records allow for the input of narrative notes as free text data. This concept has its strengths and limitations with visible impacts on nursing care.

The use of nursing narrative notes has been integral in nursing culture. Nurses rely on narrative notes for several reasons. Firstly, they help to document critical events in the management of the patient including concerns about the condition of the patient. They serve as evidence of professional competence in the field. Narrative nursing notes also differentiate different cases and individualize care, as they point out unique aspects of a case. Some clinical cases require a detailed timeline of events are they are crucial to care, for example in psychiatry and mental health. Narrative notes provide the needed transition between care points (Hall & Powell, 2013). The documented information is also in a format that nurses can easily analyze and process enhancing communication (Collins et al., 2013).

The inclusion of narrative notes in structured data fields of electronic health records promised several challenges and limitations. Paper-based nursing notes had the advantage of enhancing fluid communication and handover whereby nurses could summarize patient details and critical information or a sequence of events so that during a handover the data is already filtered and easy to process (Keenan et al., 2012). However, once entered in structured data fields this filtering of data is lost and the nurse is faced with large data sets and lost sequence of events (Embi et al., 2013).

The electronic system has another limitation in that it relies on preference and knowledge of data entry and data systems. According to Han & Loop (2007), clinicians who had poor skills navigating these electronic systems preferred using paper-based systems as they had difficulty locating, retrieving and analyzing structured data fields.

Despite the mentioned benefits and importance of nursing narrative notes, it was noted that many clinicians do not read them (Hripcsak, Vawdrey, Fred, & Bostwick, 2011). According to Hripcsak, Vawdrey, Fred, & Bostwick, (2011), authors on electronic systems spent more time writing than viewing notes with 38% of notes by nurses, 8% by residents and 16% by the attending not being read. In that study, close to 16% of all notes were never reviewed by anyone regardless of the author. This shows varied preferences in the communication channels used. The study by Brown et al. (2004) showed that physicians preferred oral communication pathways that notes further undermining the usability of narrative notes in electronic records.

Narrative Notes In Electronic Records

Another limitation to the use of narrative notes is complexity and usability. According to Kossman et al. (2008), nurses did not read their colleagues notes citing difficulty retrieving the data and charting of data as being inconsistent and cumbersome to analyze.

Comparison between paper-based documentation and electronic charting of nursing notes shows several discoveries. In a study by Kelley, Brandon, & Docherty (2011) to analyze the patient outcomes when using either system, it was unclear if any of the methods have any impact on patient outcomes. Another study by Munyisia & Hailey (2011), use of an electronic system did not reduce the amount of time spent documenting when compared to a paper system. On the contrary Hripcsak et al. (2011), found that in some cases the time spent in documentation had increased since the introduction of the electronic system. Nursing Narrative Notes In Electronic Health Records Discussion Paper

Since Keenan et al. (2012) nurses devoted 31 to 37% of their entire shift time documenting, communicating the information and retrieving, (Keenan et al. 2012), it is only logical to improve the efficiency of these documentation systems. The limitations of incorporating nursing notes into electronic systems should be managed in such a way that whenever critical information is noted in the system, it will be read and used towards patient care (Zwaanswijk, Verheij, Wiesman, & Friele, 2011).

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According to Embi et al. (2013), to ensure critical information is reviewed, co-signers to notes can be applied. This helps by flagging important events or critical issues. Another recommendation is a partnership with specialists such as educators, technical specialists, information technology staff and the makers of these electronic systems so that the use of the systems can be better understood (Sachdeva & Bhalla, 2012). Collaborating with them could help find faults and tailor the system to the needs of the current setting.

Another recommendation is the principle of supplementation rather than eradication. Each method of documentation and communication has its limitations and benefits. The nursing management should introduce electronic systems while fostering verbal communication and also allow enough time for the staff to get used to new systems.

Conclusion

The current paper aimed to critique professional communication in nursing by discussing the concept of narrative nursing notes in electronic health records. An understanding of the impact of narrative notes on communication was needed. The narrative notes were found to be beneficial in the care setting by their ability to document patient status, progress and point out critical issues and events. Incorporating them into electronic health record, however, had a limitation in that they lost their intended purpose. The notes are barely read by colleagues, are cumbersome to retrieve and analyze and lost their unique capability of filtering critical information that is helpful when handing over. The electronic system too had its strengths, being more durable, with data sets that can be easily evaluated and analyzed.

Recommendations posed to remedy and improve these systems included using a multidisciplinary approach with involvement of nursing educators, IT specialists and the electronic system vendors so as to ensure a smooth transition and efficient use of the system. Nursing management should put up measures to ensure the electronic nursing notes are read and used.

References

Blair, W., & Smith, B. (2012). Nursing documentation: frameworks and barriers. Contemporary nurse, 41(2), 160-168.

Brown, P. J., Borowitz, S. M., & Novicoff, W. (2004). Information exchange in the NICU: what sources of patient data do physicians prefer to use? Int J Med Inform, 73(4), 349-355

Cheung, C. S., Tong, E. L., Cheung, N. T., Chan, W. M., Wang, H. H., Kwan, M. W., … & Wong, M. C. (2013). Factors associated with adoption of the electronic health record system among primary care physicians. JMIR medical informatics, 1(1).

Clynch, N., & Kellett, J. (2015). Medical documentation: Part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation. International Journal of Medical Informatics, 84(4), 221-228.

Collins, S., Cato, K., Albers, D., Scott, K., Stetson, P., Bakken, S., & Vawdrey, D. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care. 22(4). 306-313.

Embi, P., Weir, C., Efthimiadis, E., Thielke, S., Hedeen, A., & Hammond, K. (2013). Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators. Journal of American Medical Informatics Association, 20, 718-726

Hall, J., & Powell, J. (2011). Understanding the person through narrative. Nursing Research and Practice, 2011.

Han, H., & Lopp, L. (2013). Writing and reading in the electronic health record: an entirely new world. Medical Education Online, 18.

Hayrinen, K., Saranto, K., & Nykanen, P. (2008). Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int J Med Inform, 77(5), 291-304.

Hripcsak, G., Vawdrey, D. K., Fred, M. R., & Bostwick, S. B. (2011). Use of electronic clinical documentation: time spent and team interactions. Journal of the American Medical Informatics Association, 18(2), 112-117.

Keenan, G., Yakel, E., Dunn Lopez, K., Tschannen, D., & Ford, Y. B. (2012). Challenges to nurses’ efforts of retrieving, documenting, and communicating patient care information. Journal of the American Medical Informatics Association, 20(2), 245-251

Kelley, T. F., Brandon, D. H., & Docherty, S. L. (2011). Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care. Journal of Nursing Scholarship, 43(2), 154-162

Kossman, S., & Scheidenhelm, S. (2008). Nurses’ perceptions of the impact of electronic health records on work and patient outcomes.Computers, Informatics, Nursing, 26(2), 69-77

Munyisia, E. N., Yu, P., & Hailey, D. (2011). Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff? International Journal of Medical Informatics, 80(11), 782-792.  Nursing Narrative Notes In Electronic Health Records Discussion Paper