Electronic documentation: how to make it better for nurses

Sharon Carpinello

I was recently reading an article by Laura Stokowski in Medscape Nurses titled “Electronic Nursing Documentation: Charting New Territory” and began wondering how electronic documentation can be better for nurses.   We are the ones who are at the bedside and focused on the patient, so why is it that at some hospitals, the IT department is driving the decisions on the systems hospitals are using?   The article states that the EHR is a “sophisticated clinical information system that extensively alters nurse workflow and processes of patient care,” but why does the EHR have to force a change in workflow?

I believe that selecting the right system is the first step toward answering these questions.  Yes, the IT department plays a critical role in the selection of a system since they will implement it and support it into the future, but the clinicians need to have a strong influence in the selection.   To assure that the expectations of the EHR “saving time and enhancing patient care” are realized, the system needs to fit a care area’s specialized workflow.   I look at the EHR as the building block for the entire house, but if that building block is a circle and the units are squares, they won’t fit together very well.  You cannot use a med/surg unit flowsheet on a Labor and Delivery unit or another care area!  The Nurses need to be involved to share their specialized workflows with IT. Nurses partnering with IT make a powerful team for choosing the most successful electronic documentation system.

Once the system is selected, the nurse’s role does not end.   The specialized care area needs to be heavily involved in the overall build and roll out.   Point of Care documentation is so critical within the Labor and Delivery unit.  We need to “paint” that picture of the mom and baby together!   The IT and clinical staff team should observe clinical workflow and then the system can be configured to match that workflow as closely as possible.   This is the one of the ways to assure that workflow is not changed drastically.   Enhancing the current workflow through electronic documentation ensures that the EHR helps the nurses, not hinders them.  Many times the only way to do this is through a specialty IT system that specifically accommodates those care areas.  The small details are the ones that can be missed trying to fit that circle into a square!  That gap is what can lead to staff dissatisfaction, and we all know what can happen when we have unhappy staff!

Even after an EHR is implemented, the nurse’s work isn’t over. It is so important to continue supporting the IT team by feeding them suggestions for improving the system.  And it’s important to give the implemented solution some time—you’ll see that with the proper steps taken, throughout the entire process, electronic documentation can work for you and your patients .

Choosing the right system and implementing it to accommodate a care area’s workflow enables nurses to practice one of the most crucial parts of their care delivery—to always put the patient first!

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