Electronic Nursing Documentation: Charting New Territory

Laura A. Stokowski, RN, MS

Disclosures

September 12, 2013

In This Article

From User-Unfriendly to Nurses' Best Friend

It was clear from the comments made by nurses that many different EHR systems are in use today, explaining the high degree of variability in functionality and user-friendliness reported by nurses. Some nurses complained of redundancy in required documentation, poor or nonintuitive organization of screens, difficulty locating where to enter data, and other system-specific issues. Sluggish system operation was a frequent complaint -- slow log-on and loading of screens (possibly related to high demand), screens freezing in the middle of documentation, loss of data (requiring the nurse to start over), and system downtime (requiring reverting to paper documentation) were sources of frustration with some EHRs. Some nurses complained of frequent system changes and upgrades, and a lack of information technology support when needed.

At the same time, we heard many variations on the theme of "electronic records are here to stay," such as this: "Electronic charting benefits the patient and streamlines their care. Nurses need to get on board and be the advocates that support this change." A nurse who moved back into a setting with paper charting "realized just how much of an advantage even an imperfect EHR was" over paper. Another said, "Anyone who wants to return to paper either hasn't given EHRs a real chance or can't remember the problems with paper -- thumbing through charts to find what you need, requesting old charts, finding the last space for a note taken and having to restock the chart before continuing, lugging charts up and down the halls...."

Still, even nurses who favor EHRs over paper acknowledge that EHRs need to evolve, and there is much room for improvement. "I love the potential for the EHR," said a reader, "but currently so little is done to pull the power of computers into actual practice." For example, many systems don't dump data from monitors and screening devices into the EHR in real time, a function that could be a significant time-saver for nurses. Joyce Sensmeier has encouraging news. "Device data that automatically populate the EHR is where we are heading."

Nurses value many aspects of EHRs, but usability is not yet where it needs to be. Nurses want an EHR that supports their work with integrated patient information, and helps them provide efficient, safe, quality care.[19] Willa Fields agrees that EHRs aren't as user-friendly as we need them to be. "We have not solved the interoperability and usability issues of EHRs," says Fields. "The EHR must complement and improve the nurse's work, rather than impede it."[19] Fields encourages bedside nurses to seize the opportunity to be part of the design team when systems are selected, configured, or upgraded. Her research shows that nurses also need education not only on the technical aspects of EHRs, but also on anticipating and managing the inevitable changes to nursing workload, workflow processes, and patterns of communication with physicians and other healthcare team members.[3]

Along these lines, Sensmeier emphasizes that "every organization needs nurses with competence in informatics so that EHR systems are configured the right way, and are helpful and meaningful," and that "chief nursing officers must advocate for what is needed to make these systems right for nurses."

How close are we to the solving the problems identified by nurses, and what does the future promise? Sensmeier responds, "We are making good strides. In another 5 years, we will be in a really good place. We will see major improvements, and will be able to look at outcomes. Moreover, the entire system will be less one-way -- it will become more interactive. It will actually give information back to the nurse in the form of clinical decision support. On the basis of intelligence (patient data entered by the nurse), the EHR will give the nurse evidence-based suggestions for nursing interventions -- a patient-specific, best-practice resource for the nurse to use."

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