(2017). The implementation of EPR as a tool for documenting healthcare has resulted in major changes and increased requirements for nursing documentation (Ammenwerth et al., 2003). Ergon. Sci. (2013). Int. Studies have shown that primary care employees often struggle to coordinate patient information in the EPRs (Gehring et al., 2012; Melby et al., 2018), and primary healthcare documentation continues to be both incomplete and inaccurate (Tuinman et al., 2017; Moldskred et al., 2020). The main social barrier associated with an increased risk of adverse events was that documentation had lower priority compared with other tasks in the caring unit. However, the social attitude was that documenting an adverse event could be viewed as a form of self-punishment rather than as an opportunity for common learning and improvement. A., and Doucette, W. R. (2018). Due to the qualitative design, the results cannot be generalized. Patient states 'Pain was better so had a good nights sleep. South. Factors Contributing to Serious Adverse Events in Nursing Homes. Quality of Nursing Documentation: Paper-Based Health Records versus Electronic-Based Health Records. Lively discussions, both in the staff focus groups and the student focus groups, contributed to rich qualitative data. Nurs. Naturalistic Inquiry. Clipboard, Search History, and several other advanced features are temporarily unavailable. Graabk, T., Terkildsen, B. G., Lauritsen, K. E., and Almarsdttir, A. BMC Nurs. One result of the different documentation practices in the various units was a fragmented documentation structure, which led to confusing patient information. Management of Health Records | HCP | Infection Control On the other hand it could have given responses based on more unequal prerequisites referring to various EPR systems. Nurs. 5, 2333393618816782333393618816780. The importance of record keeping in healthcare - Medical Defense It is important that we use many forms of record keeping and these can include e mails, incident reports, videos, photographs, text messages and tape recordings of telephone conversations. This study has identified few articles focusing on the connection between patient safety and nursing documentation practices at home health nursing services or nursing homes. doi:10.1093/intqhc/mzm042, Trnvall, E., and Jansson, I. Nurse documentation: not done or worse, done the wrong way--Part I. Descriptions of communications or EPR documentations that have caused or could cause adverse events. Additionally, there is a need observed for additional research projects that focus on students experiences regarding the practice of patient documentation and the use of EPRs. 101, 11411145. Nurs. 100-02. Med. Nurs. Aging with Multimorbidity: a Systematic Review of the Literature. What Is the Nursing Time and Workload Involved in Taking and Recording Patients Vital Signs? (2013). A lack of patient information either caused adverse events, or these adverse events were avoided by the clinical skills of the nursing staff or, as described by study informants, pure luck. Unable to load your collection due to an error, Unable to load your delegates due to an error. doi:10.1055/s-0039-1678551. Learn. 28, 27062716. (2020) and Blair and Smith (2012). In the focus group sessions, the informants discussed the lack of overview of patient information in their documentation practice. Heterogeneity in Older People: Examining Physiologic Failure, Age, and Comorbidity. How to undertake effective record-keeping and documentation Much time and effort were spent tracking answers to determine the correct administration of medications, potentially causing harm to the patients. Safer Primary Care, in A Global challenge. (2017) also recognized barriers, such as user resistance arising from data security concerns. Available at: https://ehelse.no/publikasjoner/a-brief-overview-of-health-it-collaboration-and-interoperability-in-five-countries-in-2018 (Accessed October 15, 2020). The staff informants stated that they and their colleagues did not always read the EPR when they began their shifts or did not thoroughly examine the documentation, such as when administering medications. The use of a topic-based interview guide, instead of narrow questions, contributed to data-rich discussions in the focus groups. Geriatr. Record-keeping is not done properly which is problematic, and it is 22 (12), 989997. facilitate aggregation and de-identification of information, 8.a.4. Bull. B. 10, 1. BMJ Qual. () and then they just said that I will learn this as I am working here more permanently. Health Records The WHO strategy Safer primary care focuses on nine improvement areas: patient engagement, education and training, human factors, administrative errors, diagnostic errors, medication errors, multimorbidity, transitions of care, and electronic tools (WHO, 2012). Nurses' Perceptions of an Electronic Patient Record from a Patient Safety Perspective: a Qualitative Study. (2012). All students were made aware that participating in the research would have no impact on their progression through their bachelors program. Our focus group informants discussed their common experiences of inadequacy, insecurity, and lack of knowledge regarding the ability to document patient information properly. The Answer Is 17 years, what Is the Question: Understanding Time Lags in Translational Research. Our groups discussed the lack of a transfer documenting template and the various shapes of the reports. The final technological barrier was the lack of technical support. To ensure early resolution of any health insurance grievance, policyholders should be honest when applying, keep good documentation, record-keeping, and reply promptly. I.e. However, if the doctor did not perform this task diligently, the nurses had to guess which underlying illness the patient suffered to complete their nursing observations and actions. Nord J. Soc. Formal permission to perform data collection was obtained from the authorities at all municipalities and the University College. As described by Krueger and Casey (2009), the focus group interviews were performed by two researchers: a moderator and an assistant. Gjevjon, E. L. R. (2014). Qualitative Research: Introducing Focus Groups. Documentation and Record Keeping - Susan Pirie, 2011 - SAGE These experiences prevented the informants from using the system completely. Developing and testing a nursing home end -of -life carechart audit tool. (2015). Continuity in Long-Term home Health Care. WebIn a legal sense, documentation and record keeping is also there for the protection of doi:10.1016/j.pcl.2019.03.004. (2009). The unit maintained a quality system known to everyone, and deviations from procedures were marked and reported as an adverse event and was followed up by leaders, as the procedure required. BMJ Health Care Inform. Comput. Be specific i.e. Documentation becomes a secondary issue, which I feel have to get into the heads of nurses: they must understand the importance of documentation! (2021). The study found unequal attitudes towards the documentation of adverse events, even if the informants all agreed that the public strategy in their working units was to welcome such registration. Nursing Documentation: Frameworks and Barriers. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ahgren, B. As prominent care provider, nurses have continual direct contact with patients. WebClinical documentation is an integral part of the healthcare professionals job. Disclaimer. Documentation and record keeping J. Clin. Based on similarities and differences, the codes were compared and sorted into nine sub-themes and four main themes. Virtual Health Leverage technology to expand coverage & support both in and outside of the hospital. Pneumonia in the Elderly: a Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. In contrast, a care-planning template with too much detail could overly fragment patient information and increase the risk of adverse events. Nursing staff had experienced rigid organizational EPR routines, in which only a few persons were permitted to add or change basic patient information. These focus areas are all relevant to the context of patient safety and documentation. The importance of good record-keeping for nurses. A comprehensive audit of nursing record keeping practice. All participants responded based on experiences using the same EPR system to perform documentation tasks. doi:10.3109/00365510903007018, Stevenson, J. E., Nilsson, G. C., Petersson, G. I., and Johansson, P. E. (2010). 10, 6984. 2005 Apr 20-26;19(32):48-9. doi: 10.7748/ns2005.04.19.32.48.c3846. And then there are a few who are very good at it, and the days they are not here, then it will not be done. Other routines were maintained despite an awareness of the possibility of causing adverse events. Be specific - Size of wound noted, any inflammation noted any dressings any diagrams attached. 2007 Nov 22-Dec 12;16(21):1324-7. doi: 10.12968/bjon.2007.16.21.27718. Involving municipalities with other EPR solutions could have expanded the picture of challenge. Social educators are employed in municipal care: in nursing homes and home healthcare units in Norway. This inappropriate routine was confirmed by the student informant groups, who faced even more substantial challenges when attempting to retrieve information from multiple sources. Another example was not being aware of a missing blood sampling that was necessary to perform medication adjustments, resulting in incorrect medication; this error was recognized as a potential patient safety risk. Documentation and Record Keeping Thompson GN, McClement SE, Labun N, Klaasen K. BMC Palliat Care. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication. Br J Community Nurs. EPRs represent a communicative and collaborative tool, in addition to serving as the written record for which actions have been implemented. Descriptions of daily nursing and care planning, communications, and documentation processes. A Systematic Review. Reasons for not using the tablet PC for documentation were not provided in our result. To stay updated. Our participants indicated inadequacy, insecurity, and lack of knowledge among their individual challenges but did not necessarily describe these issues as part of the organizational strategy because they had all received training sessions within their units. DOCUMENTATION doi:10.1136/bmjqs-2015-004178, Patel, S. J., and Landrigan, C. P. (2019). Aging Populations and Management. Time shortage or not sharing the same sense of responsibility for documentation were the explanations given for not accomplishing documentation tasks, either in a standardized way or at all. Web10.12968/bjon.2011.20.22.1450 Abstract Record keeping is an essential part of nursing Soc. This theme includes two sub-themes and refers to the barriers associated with personal characteristics that may influence a staff members documentation practices. The years between data collection and publication may be seen as a limitation in the study, but we have also learned that changes due to digitalization in healthcare take many years to implement and adopt, as described by Morris et al. Factors Affecting and Affected by User Acceptance of Computer-Based Nursing Documentation: Results of a Two-Year Study. Document everything () everything done in a day, while others are better at documenting what is relevant for the patient care () And some do not write at all. electronic or paper), good What to Expect from Electronic Patient Record System Implementation: Lessons Learned from Published Evidence. WebConsistent, current and complete documentation in the medical record is an essential Pilot Feasibility Stud. J. This particular EPR solution, as is the case for the other two EPR systems, offers an enlarged EPR solution where the EPR module is connected to other relevant modules; for example, basic personal information, billing, and medication order modules. J. Clin. Encountering this barrier would result in participants leaving the computer without logging off as expected, or they would ask a colleague to perform documentation on their behalf to avoid using their time for waiting for system access. The interview guide included these areas: Descriptions of patient information exchanges, collaborative procedures, and documentation practices applied during patient transfer. Samhandlingsreformen. Health Care 19 (6), 349357. BMC Nurs. Res. Webnationally-consistent education on topics of interest to health care professionals. Res. doi:10.1111/jocn.14873, Panesar, S. S., deSilva, D., Carson-Stevens, A., Cresswell, K. M., Salvilla, S. A., Slight, S. P., et al. Unstable system access, deficient EPR usability, and poor user interfaces, together with scarce technical support, did not support their nursing practice needs. 25 (2), 92104. Please enable it to take advantage of the complete set of features! Similar negative attitudes toward documentation have been reported previously, such as in Bgeskov and Grimshaw-Aagaard (2018) research, in which nurses in hospitals perceived documentation as being a meaningless burden that hindered them from focusing on the patient. Even though the informants of this study had experience using the same EPR system, each municipality was able to some extent to technically adjust the system setup according to their existing or desired organizational routines. Nursing Informaticians Address Patient Safety to Improve Usability of Health Information Technologies. Give more detail when did they state they were dizzy were observations recorded what follow up is planned? In the focus groups, the participants were invited to reflect upon and compare each others views and experiences to contribute to a broader understanding of patient safety and documentation practices (Kitzinger, 1995). It is important that others can understand what you have recorded, and what that means for the service user you have been caring for. 17, 645. doi:10.1186/s12913-017-2600-x, Olsen, R. M., Hellzn, O., Skotnes, L. H., and Enmarker, I. The Role of the Norwegian Social Educator. (2019) also found correlations between organizational issues, such as work environment, patient safety and EPR system usability. Safety Documentation and Record Keeping One strength of this study is that the sample included a combination of healthcare professionals with considerable experience and bachelor-degree students with an outside view of the workplace. We would like to thank our participants, students and nursing staff participants as well as their leaders for time spent in the focus group discussions: for sharing experiences and thoughts with the research team in order to achieve the results of the study. Uncovering whether EPR solutions meet professional needs with regard to patient information. Documentation and record keeping is an important aspect of healthcare Usability and interface problems also included small fonts and compressed text that made information difficult to read and was another possible risk for adverse events. What Are the Principles that Underpin Integrated Care?. doi:10.7748/ldp.2016.e1810, Helleso, R., and Ruland, C. M. (2001). The Importance of Good Documentation in Nursing - Newcross nursing documentation How to undertake effective record-keeping and For many years, the quality of nursing documentation has been reported as inadequate (Helles and Ruland, 2001; Blair and Smith, 2012; Akhu-Zaheya et al., 2018). Medicare Benefit Policy. This could further have drawn attention away from challenges described in the result of this study, and more toward variations between EPR systems as such. The authors listened to each recorded interview and simultaneously read the transcribed text to obtain an overall view of the data. doi:10.5334/ijic.1884, Gautun, H., and Syse, A. This growing patient population will require both complex medical treatment and nursing care (Ministry of Health and Care Services, 2012; Kulik et al., 2014). Documentation and Record TABLE 1. When informants experienced problems, such as the system being down or log-on problems, these issues could only be addressed during a normal working day between 08:0016:00, with no support offered during night shifts, weekends, or holidays. 1. doi:10.3233/978-1-61499-951-5-501. A literature review by Gesulga et al. doi:10.1111/jgs.15389, Ammenwerth, E., Mansmann, U., Iller, C., and Eichstdter, R. (2003). Careers. 20 (2), 245251. They reported low confidence in their own and their colleagues ability to place documentation elements correctly in the EPR system, resulting in a fundamental concern regarding the quality of patient documentation and a constant fear that adverse events will occur. Health service leaders and ICT leaders should pay close attention to system implementation and adoption phases: This study shows the need for these leaders to pave the path for their staff members and not to underestimate the complexity in documentation and information exchange in their caring units: all in order to secure and improve patient safety. six of the students were in their final semester of a 3years degree program, and five were in their penultimate year. Data were analyzed using qualitative content analysis. WebWe observed 22 health care workers across intensive care units, inpatient floors, and an To ensure the effective use of healthcare resources and improve patient outcomes, many Western countries are attempting to transfer responsibilities from specialist care to primary care. Invest. Frank-Stromborg M, Christensen A, Elmhurst D. Oncol Nurs Forum. The inclusion criteria for the nurses and social educators included that they were employed in primary healthcare (nursing homes or home nursing care) and that they were involved in direct patient care. Staff members in long-term elderly care often know their patients quite well and, therefore, may find documentation redundant because they maintain a lot of information in their heads (stensen et al., 2019). Some of us document and take it very seriously. It would seem appropriate firstly to consider what is meant by the terms documentation and record keeping. Record keeping is an essential part of nursing practice with clinical and legal significance. Assessing Adverse Events Among home Care Clients in Three Canadian Provinces Using Chart Review. limit access only to authorized personnel, 8.a.2. Mann R, Williams J. doi:10.1111/jocn.13914. When the safety culture within staff groups undermines documentation tasks, identifying whether the underlying reasons for these attitudes and behaviors are associated with the priority of direct patient care or whether other causalities exist is imperative (Barkhordari-Sharifabad et al., 2017). The .gov means its official. WebEstablish systems to maintain confidential work-related healthcare personnel health Nurs. Med. An official website of the United States government. 75 (7), 13791393. One student representative had the following experience: One of our patients had anti-constipation treatment without being constipated: His elimination status was just not recorded anywhere. Med. 124, 544551. The study was implemented in accordance with the Declaration of Helsinki (World Medical Association, 2001). Staff informants had experienced not being allowed to add medical diagnoses to the EPR system because this task was reserved for the patients doctor. Priestman, W., Sridharan, S., Vigne, H., Collins, R., Seamer, L., and Sebire, N. J. 2021 Jan 27;7(1):33. doi: 10.1186/s40814-021-00768-5. WebForemost of such electronic documentation is the electronic health record (EHR), provides an integrated, real-time method of informing the health care team about the patient status.Timely documentation of the following types of information should be made and maintained in a patientsEHR to support the ability of the health care team to ensure Lincoln, Y. S., and Guba, E. G. (1985). During hectic shifts, our informants would rather relieve their colleagues than update the EPR. Documentation and record keeping is an important aspect of healthcare practice and perioperative practice is no exception to this rule. J. Clin. Health Technol. One area associated with severe patient risk that was reported in our work was nursing staff not correctly updating or carefully reading the EPR when handling medication. Stud. (2010) and followed up by a study in 2012 where nurses reported that the EPR does not support their nursing practice (Stevenson and Nilsson, 2012). Take a look at our current nursing vacancies today! Basic information and communications technology (ICT) skills varied among the participants and strengthened the sense of insecurity described above. doi:10.1111/jocn.14097, PubMed Abstract | CrossRef Full Text | Google Scholar, Al-Jumaili, A. what the patient states e.g. Multiple areas could be used to document the same information within the EPR system, which made documentation fragmented and difficult to rediscover when the nursing staff required the information. Medical record keeping: clarity, accuracy, and timeliness are government site. doi:10.1016/j.aorn.2009.09.014, Moldskred, P. S., Snibser, A. K., and Espehaug, B. It is central in our caring to spend time with the patient. doi:10.1016/j.gerinurse.2017.04.007. The elderly population is expected to grow in both European and American countries in the near future, which will be accompanied by increased demand for elderly healthcare services. This ability resulted in some variety in documentation routines. Standards in medical record keeping. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events (Emanuel et al., 2008, p. 16). doi:10.1201/b10942, Dunn Lopez, K., Chin, C.-L., Leito Azevedo, R. F., Kaushik, V., Roy, B., Schuh, W., et al. 2022 Feb 23;15:1945-1956. doi: 10.2147/IJGM.S346366. Thus, informants reported both shared and unique organizational documentation challenges and barriers between the focus groups. J. Clin. In one of the student groups having experiences from a variety of municipalities, this frustration was shared: A big source of error is that you always have to remember where to look for things; where to check the patch, the medications, where to find time appointments, and there, and there, and there and in addition you have to take care of the patients and keep them in mind, and then you have to keep in mind if there is any wound procedure, and then you have to keep in mind inhalation and the eye drop form in the closet, and. Introduction. Earlier Hospital Discharge: a challenge for Norwegian Municipalities. Krueger, R. A., and Casey, M. A. (2017). Trondheim: Norwegian University of Technology and Science. What were your actions Has care changed following fall? Geneva: Word Health OrganizationAvailable at: https://www.who.int/patientsafety/summary_report_of_primary_care_consultation.pdf (Accessed October 15, 2020). Home-health nurses might not have access to online EPRs, which would allow for them to consult previous nursing interventions and evaluations, and they must perform their own documentation, which they may be unable to do until they return to the home care center office (Olsen et al., 2013). The Safer Primary Care Expert Working Group. A link between patient safety and inadequate documentation has previously been reported by studies examining documentation and adverse events in primary care. Nursing Research: Generating and Assessing Evidence for Nursing Practice. Be specific Was it witnessed? Thus, we suggest that the experiences will still be relevant for healthcare organizations preparing for the implementation of ICT tools. Even though EPR was implemented over a decade ago and is widely used in primary care in Norwegian municipalities, healthcare services continue to face documentation challenges that result in adverse events. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=106094131&site=ehost-live (Accessed October 15, 2020). J. Manag. (2011). doi:10.1197/Fjamia.M111810.1197/jamia.m1118, Andersson, ., Frank, C., Willman, A. M., Sandman, P.-O., and Hansebo, G. (2018).

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