Clinical Documentation and Nursing Practice

The Importance of clinical documentation in nursing is evident. Electronic clinical documentation facilitates communication of patient progress among interdisciplinary team members. Standardized clinical documentation in nursing remains complex.

There is clinical evidence in literature associating the delivery of nursing care to clinical documentation. Electronic documentation promotes the accuracy, continuity of care, and safe patient handoff and transition of care.


Healthcare facilities continue to invest in electronic health records to maximize reimbursement and to benefit from grants and other incentives. Shortly, nurses must become computer literate to remain competitive and competent in the healthcare industry.

The nursing profession continues to evolve with the implementation of electronic documentation in healthcare worldwide. There will be an increased demand for electronic gadgets with advanced technical features. Thus, nurses ought to adapt to the advancement in technology.

History Of Electronic Documentation

Informatics has been around since early 1800 with Herman Hollerith, who invented the Tabulating Machine. Moreover, health informatics started evolving in 1950 with the integration of computers in healthcare. This new initiative is progressively replacing paper charting, which is often cumbersome, hard to read, time-consuming, and challenging to store.

Paper or manual documentation was the approved format for many years in nursing. Baby boomer nurses are very comfortable with paper charting. With the evolution of clinical documentation in nursing, the Center for Medicaid and Medicare-CMS requires a healthcare facility to convert to Electronic Health Records (EHR) to maximize payment.

There is a significant promotion for electronic documentation systems across the United States. In 2011, Institute Of Medicine – IOM strongly recommended the use of technology to improve the quality of care provided to hospitalized patients

impact of electronic documentation on nursing practice

Clinical Documentation and Delivery Of Care

Electronic clinical documentation is accessible to several team members simultaneously. Thus, clinical documentation is easy to store in the database. With the adoption of clinical documentation, nurses will communicate more effectively with interdisciplinary team members. Besides, the system will also promote transparency in the delivery of care.

Nurse leaders understand the importance of clinical documentation in nursing will facilitate data collection. Therefore, nurse leaders support the initiative by allocating resources for the operations of nurse informatics. Nurses will no longer rely on human memory to document pertinent information.

During the assessment, nurses have the option to select a system-generated nursing diagnosis. For instance, the electronic system contains an approved nursing diagnosis and care plan options based on admitting diagnosis. Many clinicians believe that electronic documentation will improve the delivery of care.

Clinical Documentation And Evidence-Based

Millennial nurses are younger and very receptive to electronic documentation. Their positive behavior validates the importance of clinical documentation in nursing. The integration of electronic charting will enable nurses to perform on-time charting at the bedside. This Initiative will improve the patient-nurse therapeutic relationship.

Following the implementation of Electronic Health Records in a Florida hospital, a doctoral student from the University of Miami and a Ph.D. instructor conducted a pilot study on a medical-surgical nursing unit. They evaluated the quality of care using electronic documentation versus paper-based documentation.

In a 560 beds medical center, the team reviewed 139 patients’ records. The team also performed a comparative analysis between electronic and manual charting. A descriptive study was completed, and there was evidence that electronic documentation improves the quality of care.

The study also established a direct relationship between electronic documentation and communication among interdisciplinary team members. Also, it validated the ability to collect and analyze data and trends in nursing documentation for consistency. The team found eleven out of one hundred thirty-nine documentation inconsistent and incomplete.

Inclusion criteria were electronic documentation in nursing, and the study was conducted in one setting. The study was limited because the clinical documentation focused mainly on pressure ulcers in acute care. Therefore, the writer suggests further studies to evaluate the effectiveness of electronic clinical documentation in nursing. The subsequent studies should also evaluate the importance of clinical documentation in nursing across all care settings.

impact of clinical documentation on nursing care

Implications For Nursing

With the evolution of informatics in nursing, there are many opportunities for nurses to advance their knowledge in electronic data management systems. The Center for Medicare and Medicaid Services – CMS encourages providers and healthcare facilities to adopt electronic clinical documentation to improve patient outcomes.

A former United States executive was very supportive of electronic health care records in 2005. Besides, In 2007, President Bush Administration dedicates 100 million dollars to test technology projects related to Electronic Health Records-EHR. This action truly validates the impact of electronic documentation in nursing and promotes leadership engagement.

Nurses will become proficient in technology and will be able to complete electronic documentation as established by healthcare facilities. Besides, nurses should adapt to new informatics initiatives and comply with electronic records regulations.

Clinical electronic documentation will enable nurses to perform on-time charting at the patient bedside, and access patient records remotely. Some nurses might be apprehensive about changes in the electronic documentation due to a knowledge deficit in technology. Further clinical studies are necessary to evaluate the relationship between clinical documentation and patient outcomes.


There should be additional studies that focus on patient perceptions about clinical documentation and impact on the delivery of nursing care. Besides, studies should analyze the time nurses spend to perform electronic charting each shift. Subsequent research should focus on nursing attitude toward electronic documentation. Finally, clinical studies should be conducted across the country in different care settings using a mixed sample with a diverse background.

Conclusion

 Clinical informatics has changed nursing in many ways, and nurses will need to be proficient in electronic data management. Paper-based documentation will soon become obsolete over electronic clinical documentation. Many facilities have invested millions of dollars In expanding healthcare delivery and complying with federal recommendations in managing patient records.

After a thorough analysis of peer-reviewed articles, it is evident that the integration of electronic documentation has directly impacted the delivery of nursing care. Nurses should complete training and obtain new knowledge about the new system and associated features.

The costly investment is an incentive to higher reimbursement for services provided. The nursing trends will continue to exhibit the expansion of electronic clinical documentation to promote a positive impact on patient outcomes and satisfaction. Therefore, there is a significant need for the nursing curriculum to incorporate informatics and technology in the program.

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