Nursing Documentation in the Age of the Electronic Health Record - Research Paper Example

? Nursing Documentation in the Age of the Electronic Health Record Nursing Documentation in the Age of the Electronic Health Record Introduction Health care providers and administrators view record keeping as a critical element that promotes safety, quality, compliance and continuity of service. Nursing documentation is surrounded by a variety of tensions such as the amount of time spent on preparing documents, number of errors in records, the need to promote legal accountability and the necessity of ensuring understandability of nursing notes to other disciplines. Deficiencies in nursing recording have forced the stakeholders to implement interventions aimed at improving healthcare documentation. Healthcare providers need to determine the best approaches for incorporating the elements of nursing into Electronic Health Records. Electronic documentation ensures long-term preservation and storage of records, which promotes evidence-based nursing care (Busch, 2008). Capturing nursing’s independent contributions to patient care requires proper comprehension and application of standardized terminologies that reflect the uniqueness of the healthcare systems. Correct use of standardized terminologies benefits the nursing profession through enhancing communication among the nursing stakeholders, increasing visibility of nursing interventions and facilitating assessment of nursing competency. The Focus of Documentation of Patient Care Information recording is a critical part of medical endeavor. Busch (2008) maintains that medical care requires continuous flow of information before and after each task to maintain continuity of care. The tasks in the medical care are interdependent and build on one another to achieve the goals of nursing practice. Nurses have the responsibility of managing and implementing the plans of the medical team for the patient through recording the progress towards the outcomes. Nurses collect the patient’s information during diagnosis and record the same in files kept in the hospitals. The objective of collecting this information is to enable the nurses to trace the medical history of the patients during diagnosis in order to help them identify genealogical and chronic diseases. Future nurses for patients will also need this data for understanding the earlier medicine and its effects on the patient over time. Lack of documentation may lead to lose of crucial information required by both the nursing organization and the patients (Azari, Janeja & Mohseni, 2012). Practicing nurses, therefore, need to be educated to the necessity of documenting care using standardized nursing languages in this era when sectors are rapidly embracing electronic documentation. Documentation in healthcare focuses on enhancing communication and continuity of care among the nurses and other healthcare professionals involved in the profession. Communication between the nurses and the nurses and among doctors cannot be possible, unless there is proper documentation. Doctors do not meet physically to discuss the progress of patients in most cases; documents are sent from one section of the hospital to another for the intended provider to act appropriately (Busch, 2008). Proper documentation stimulates the process of communication in the hospital, which ensures that the healthcare stakeholders achieve their objectives. Another focus of medical documentation is ensuring evidence for future reference. There are cases where doctors give incorrect medication to patients. These patients may develop complications, which may lead to legal liabilities. The courts of law require the records to serve as evidence for incorrect treatment disseminated. Documentation ensures that these records are available whenever required. Additionally, proper documentation leads to recording of data that is crucial for research and education (Ripley, 2009). Practicing students of medicine and nursing can refer to these documents when there is a need to link theoretical knowledge to practical knowledge. Documentation, therefore, ensures safekeeping of records for future reference for educational reference and evidence of medication in the courts of law. Medical documentation is required for accreditations and attaining the legal standards. One of the requirements for being accredited is having dependable and consistent record keeping procedures. International standards such as ISO 2700:2005 standards specify that nursing practitioners should have to maintain complete records of their assets and liabilities. Only registered users will have the responsibility of accessing health care records, and they should provide the required credentials in order to log into system records. Failing to have proper documentation may lead to legal liabilities to the hospitals (Busch, 2008). Thus, proper documentation focuses on attracting international accreditations and avoids further legal liabilities. Most hospitals use Artificial Intelligence (AI) in record keeping. Electronic Healthcare Record (EHR) is a form of AI, which has been implemented in the healthcare sector with the primary objective avoiding time wastage. Effective time management is not possible in hospitals that use manual records. The Electronic HealthCare Record integrates data from various healthcare providers to create a common record for each patient. This enables various healthcare providers to view the earlier treatments that patients received to provide the required medication. Doctors from different departments can access and rapidly communicate particular patient’s test result such as x-ray as soon as it is entered in to the computer confidence. During emergencies, doctors use the patient’s identification card to access time-critical information such as allergies, blood groups, recent treatments and ongoing medication (Azari, Janeja & Mohseni, 2012). The EHR is a source of data for national statistics, which is used by health ministry to identify health trends of the population, track health epidemics and monitor the use of public health funds to ensure they help the relevant populations. The primary objective of medical documentation is reducing errors prone in the healthcare records. These errors include errors of omission, misinterpretation and redundancy. Medical record documentation is required to keep correct and accurate pertinent facts, observations and findings (Ripley, 2009). These relate to the patient’s examinations, outcomes, treatments and tests. Recording chronologically documents the care of the patient, which contributes high quality nursing care. Accuracy in records ensures defect-free nursing services to the patients. Erroneous records cannot support the quality of patient care because presentation of records with omitted details that may lead to misinterpretation of the patient’s diseases and possible prescription of incorrect medication. Busch (2008) investigated whether medical practitioners use medical records for the purposes they are actually intended. There are tremendous potentials that the digitization of health care documentation promises to the healthcare industry. The problematic aspect of Electronic Healthcare Records is the possibility of such records becoming pervasive and powerful means of committing healthcare frauds. Healthcare providers sometimes use this advanced technology to interfere with the medical system with the objective of obtaining payments to which they are not entitled. This becomes a possibility because the Electronic Health Record can automatically generate deceptive patient histories. Doctors can also copy and paste the same results from examination for multiple clients. Investigation reports reveal that medical professionals hiked their billings to the Medicare program by using remunerative billing codes that through creating detailed patient files (Azari, Janeja & Mohseni, 2012). The use of Electronic Health Records has led to increased number of hackers interested in the patients’ medical records. Hackers steal backup tapes that contain health insurance records for patients. The hackers are interested in finding the medical history and examinations of prominent people and military officials. The United States Department of Defence, for example, reported that a number of backup tapes were stolen from a contractor for TRICARE, an agency that provides health insurance to the members of the armed forces (Azari, Janeja & Mohseni, 2012). According to the reports, personal data and medical documents of five million patients treated at the military for twenty years was compromised during this incidence. Standardised Nursing Terminologies and the Associated Concepts Schwirian (2013) argues that it is impossible for medicine, nursing or any healthcare-related industry to design and implement electronic documentation without proper understanding of the standardized nursing terminologies. The standardized terminologies act as a language or vocabulary that describes the key components of the Electronic Health Records. A key element in the nursing profession lies in professional languages that that describe and evaluates the quality of patient care. The development of standardised nursing terminologies proceeded during the early 1990s (Schwirian, 2013). Medical specialists have developed terminologies that reflect different kinds of nursing practice and incorporate various conceptual foundations. The standardised nursing terminologies available comprise of seven interface terminologies. Clinical Care Classification (CCC) The Clinical Care Classification System is a standardized code that identifies the discrete elements of the nursing process. Schwirian (2013) contends that the Clinical Care Classification provides a unique framework and a structure of coding for documenting the plan of care by following the nursing process in medical settings. The CCC consists of two unrelated terminologies: the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions. This classification is made by 21 Care Components, which link the two categories and enables mapping to other health-related systems of classification (Saba, 2007). The CCC is a research-based terminology, which started with a community focus and includes nursing diagnoses, interventions and outcomes. The creators of the CCC intended the system to be computerized; however, some components have not been computerized. Omaha System The Omaha System is research-based, standardized taxonomy and comprehensive practice that is meant for documenting client care from the time of admission to discharge. The system enables medical practitioners to collect, aggregate, and analyze clinical data with an objective of enhancing communication, critical thinking, and quality of services (Schwirian, 2013). The Omaha System is designed with a structure that supports computer compatibility. The Omaha System consists of the three components: assessment, intervention and outcomes components. These components are arranged to form the three schemes of the Omaha System; these are problem classification scheme, intervention scheme and the problem rating scale for outcomes (Busch, 2008). The system was initially used for home care, but it has evolved over time and is presently applied in several nursing care settings including the intensive care unit. Nursing Intervention Classification (NIC) Nursing Intervention Classification is a standardized nursing terminology that highlights the activities performed by nurses during the planning phase of the nursing process in creating healthcare plans (Schwirian, 2013). The objective of the Nursing Interventions Classification is to ease the process of selecting an intervention plan suitable for a specific situation. The NIC also enables nurses to use a computer to describe the intervention using standardized levels for classes and domains. The Nursing Interventions Classification comprises of a four-level hierarchy system. The first two levels of the NIC are made up of a list of four hundred and thirty-three interventions each defining general term (Thede & Schwiran, 2011). The first two levels also bear a ground-level list of exact activities that a nurse performs to carry out an intervention. The last two levels of the NIC make a taxonomy, which groups each intervention into twenty-seven classes; each category is classified into six domains. The NIC is useful for clinical documentation, communication, data integration, competency evaluation and productivity measurement. Nursing Outcomes Classification (NOC) The Nursing Outcomes Classification (NOC) is a terminology that describes patient outcomes that are sensitive to healthcare intervention process. This standardized nursing terminology evaluates the results of nursing care throughout the nursing process. This terminology comprises of three-hundred and thirty outcomes, each bearing a label, definition, a set of performance indicators and measurement parameters that determine the achievement of the nursing outcome (Schwirian, 2013). The NOC measures the perception and behavior, an individual, family or a community state along a continuum to investigate the responsiveness of these parties to nursing interventions. The outcomes of NOC are divided into seven domains, which include functional health, community health, physiologic health, family health, psychological health, perceived health, health knowledge, and behavior (Thede & Schwiran, 2011). Health measurement of both the individual and the population is a critical determinant of the nursing outcomes. This standardized terminology is based on measurable parameters that determine the rate in which the nurses achieve the nursing outcomes. North America Nursing Diagnosis Association (NANDA) International NANDA International is a professional organization that was officially founded in the year 1982 to develop research, disseminate and refine the taxonomy, nomenclature and taxonomy of nursing diagnoses (Schwiran, 2013). These diagnoses are used for choosing proper nursing interventions and establishing desirable patient outcomes. NANDA broadened its scope of membership and went international in the year 2002 (Busch, 200). NANDA has a historical significance as a foundational element of the Standardized Nursing Terminologies. due to its centrality as a developer of Norma Lang. The NANDA standardized nursing terminology is updated after every two years (Schwirian, 2013). International Classification for Nursing Practice (ICNP) The ICNP is the newest classification of the standardized nursing terminologies that has been accepted by the America Association of Nurses. The International Classification for Nursing Practice emerged as a result of a proposal that was addressed to the International Council of National Nurses seeking development of a standardized vocabulary and proper classification of nursing interventions that would be useful in manual and electronic records (Schwirian, 2013). ICNP was meant to be part of a worldwide infrastructure developed for purposes of improving healthcare policy and patient care across the world. This standardized terminology involves a common language that describes nursing care and stimulates nursing research through ensuring effective communication. Perioperative Nursing Data Set (PNDS) Perioperative Nursing Data Set is a research-based system with an easily automated nomenclature, which can describe the specialty practice of nursing. The PNDS comprises of four domains: safety, health system, physiologic response to surgery and family and patient behavioral response to surgery (Schwirian, 2013). The physiology, patient and the family have different reactions to surgery; the Perioperative Nursing Data Set analyzes these responses and initiates desirable intervention mechanisms. Each domain has the desired outcome interventions and diagnoses that are characterized by content validity, reliability and construct validity (Busch, 2008). PNDS describes the nursing intervention to the patient beginning from the time of admission to discharge with the use of standardized elements. The Role of Electronic Documentation Using Standardized Terminologies in Informing Evidence-based Nursing Care The nursing practice involves the collection, evaluation, storage and retrieval of information gathered from an individual, family or community (Schwirian, 2013). The primary objective of electronic documentation is to collect information required to identify the problems of patients and symptoms that are sensitive to the nursing practice. Nursing assessment, therefore, provides an evidence base for making communications and referrals to other disciplines. The database of nursing assessment avails the foundation of care planning and the basis for evaluating the status of the patients. Accurate, complete and ubiquitous patient assessment data and information lead to effective care and automation of data (Saba & Taylor, 2007). Electronic documentation promises error-free data and information that can be used as evidence that the nursing intervention occurred. An accurate nursing database is a critical element in the nursing profession because it ensures effective communication, easy problem identification, making intervention plans and evaluation of patient progress through the recovery process. This is because accurate databases avail up-to-date information that is used by the nurses in their professional practice. A detailed model of assessment data maintains the quality of data, consistency in documentation and support evidence-based planning in the nursing practice. Data stored is used for supporting the evidence that the medical intervention really took place and the nurse who is responsible for the alleged nursing process. Standardized nursing terminologies and guidelines support the diagnoses, interventions and outcomes of the nursing process through availing evidence of prior treatments (Thede & Schwiran, 2011). Electronic documentation enables transmission of data through a codified format. Standardized content alone is not sufficient to support evidence-based nursing practice. Medical practitioners capture atomic level data that reflects actual patient status. This data needs to be transferred through a structured and codified format to make it possible for easy storage, retrieval and analysis, in both the present and the future. The use of ICNP, for example, provides a foundation for capturing atomic level data (Thede & Schwiran, 2011). This data is processed into information, which is used to guarantee evidence-based practice. This leads to decision support for applying evidence for practicing and building further evidence from the practice. Differences between the Nursing Minimum Data Set and Nursing Focused Terminologies The Nursing Minimum Data Set is a system of classification, which enables nurses to collect standardised data. An NMDS comprises of a minimum data set of information having uniform categories and definitions concerning a particular dimension of nursing that have the potential of meeting the needs of multiple data users in the nursing profession (Schwirian, 2013). The objective of collecting standardized data is to ensure accuracy in the nursing process when providing care. This system allows the nursing researchers to analyze and compare data across populations, time, geographic areas and social settings (Ripley, 2009). Nurses collect information during assessments. The records contain spaces for date and place of origin of the patient. The NMDS is one of the attempts to standardize the collection of data that is critical to the nursing process. The minimum care data provides an accurate analysis of nursing diagnoses, care and resources used in the nursing process. The Nursing Minimum Data Set enables nurses to compare data among the populations across time and settings. Nursing Focused Terminologies are a set of vocabularies that are used among the nurses during the process healthcare provision. The nursing terminologies are controlled and meant to meet the needs of only the intended end-users. Wide differences in terminologies in the use lead to difficulties when comparing and exchanging healthcare information (Khoumbati, 2010). Nursing organizations across the world have developed a coherent range of terminologies to avoid the adversities associated with the use of multipurpose terminology. The best example of nursing terminology constitutes the seven accepted standardized nursing terminologies that are acceptable and used throughout the world (Ripley, 2009). The standardized nursing terminologies include the Clinical Care Classification, Omaha System, Nursing Intervention Classification, Nursing Outcomes Classification, NANDA International, International Classification for Nursing Practice and Perioperative Nursing Data Set. Case Study: Lippincott’s DocuCare Lippincott’s DocuCare was founded as faculty collaboration at the University of Tennessee Knoxville. The Lippincott’s DocuCare group was initially named iCare (Lippincott, 2012). The primary objective of this group was to develop educational health record for students’ practice. The qualities of the electronic health records developed by iCare included affordability, ability to prepare students for practice and meet educational needs of the students. The need to enhance the educational EHR to fit the requirements of all programs led to collaboration between Lippincott Williams and Wilkins with an objective of meeting documentation needs for preparing students for practice (Schwirian, 2013). The collaboration led to establishment of Lippincott’s DocuCare team. The team is currently devoted to quality services and achieving the original goals of iCare. Lippincott’s DocuCare has really boosted the development of electronic health records for educational purposes (Lippincott, 2012). The success of Lippincott’s DocuCare comes from the team’s dedication to collect and store more than one-hundred and fifty patient records. These records contain a wide range of diseases and conditions across the lifespan and curriculum. Conclusion Documentation in nursing focuses on ensuring a continuous flow of information before and after every task. Documentation enables the nurses to trace the medical history of the patients during diagnoses and treatments. Practicing nurses need to be educated on the necessity of documenting care using standardized nursing languages in this era when sectors are rapidly embracing electronic documentation. Proper documentation stimulates the process of communication in the hospital and guarantee safekeeping of records for future reference. Medical documentation focuses on attracting international accreditations and avoiding further legal liabilities. Electronic documentation, however, has led to hacking of health records of patients. This has led to compromise of patients’ personal data. A key element in the nursing profession lies in professional languages that describe and evaluate the quality of patient care. Electronic documentation promises error-free data and information that can be used as evidence that the nursing intervention occurred. A detailed model of assessment data maintains the quality of data, consistency in documentation and support evidence-based planning in the nursing practice. Electronic documentation enables transmission of data through codified formats that are sufficient in supporting evidence-based nursing. Nursing Minimum Data Set enables nurses to compare the healthcare data to discover inconsistencies in intervention processes. The nursing profession has developed a coherent range of terminologies meant to avoid the confusions associated with the use of multipurpose terminology. References Azari, A., Janeja, V. P., & Mohseni, A. P. (2012). Healthcare Data Mining: Predicting Hospital Length of Stay (PHLOS). International Journal of Knowledge Discovery in Bioinformatics, 3(3), 44-66. Busch, R. S. (2008). Electronic health records: An audit and internal control guide. Hoboken, N.J: Wiley. Khoumbati, K. (2010). Handbook of research on advances in health informatics and electronic healthcare applications: Global adoption and impact of information communication technologies. Hershey PA: Medical Information Science Reference. Lippincott, W. W. (2012). Taylor's handbook of clinical nursing skills + lippincott's docucare, 18-month access. S.l.: Wolters Kluwer Health. Ripley, B. D. (2009). Pattern recognition and neural networks. Cambridge: Cambridge University Press Saba, V. K. (2007). Clinical Care Classification (CCC) System manual: A guide to nursing documentation. New York: Springer Publishing. Saba, V. K., & Taylor, S. L. (2007). Moving past theory: Use of a standardized coded nursing terminology to enhance nursing visibility. Computers in Nursing, 25(6), 324-331. Schwirian, P. M. (2013). Informatics and the future of nursing: Harnessing the power of standardized nursing terminology. Bulletin- American Society for Information Science and Technology, 39(5), 20-24. Thede, L., Schwiran, P., (2011). Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experiences and Attitudes. The Online Journal of Issues in Nursing, 16(2), 1-17. Read More