Health Information Technology,
Patient Safety, and Professional
Nursing Care Documentation in
Acute Care Settings
...the EHR [is] seen
by nurses as both a
benefit and a
source of
considerable
frustration.
Abstract
Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN
Ellen Harper, DNP, RN-BC, MBA, FAAN
Nancy Barr, MSN, RN
The electronic health record (EHR) is a documentation tool that yields data useful in enhancing
patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs.
Although nurses applaud the EHR, they also indicate dissatisfaction with its design and cumbersome
electronic processes. This article describes the views of nurses shared by members of the Nursing
Practice Committee of the Missouri Nurses Association; it encourages nurses to share their EHR
concerns with Information Technology (IT) staff and vendors and to take their place at the table
when nursing-related IT decisions are made. In this article, we describe the experiential-reflective
reasoning and action model used to understand staff nurses’ perspectives, share committee
reflections and recommendations for improving both documentation and documentation technology,
and conclude by encouraging nurses to develop their documentation and informatics skills. Nursing
issues include medication safety, documentation and standards of practice, and EHR efficiency. IT
concerns include interoperability, vendors, innovation, nursing voice, education, and collaboration.
Citation: Lavin, M., Harper, E., Barr, N., (April 14, 2015) "Health Information Technology, Patient Safety, and
Professional Nursing Care Documentation in Acute Care Settings" OJIN: The Online Journal of Issues in Nursing
Vol. 20 No. 2.
DOI: 10.3912/OJIN.Vol20No02PPT04
Keywords: Experiential-reflective reasoning, electronic health record, informatics, informaticists, nursing practice,
health information technology, standards, documentation, quality, safety, patient responses, patient outcomes
The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety,
evaluating care quality, maximizing efficiency, and measuring staffing needs (Beck et al., 2013; Harper, 2012a;
Towsley, 2013). Although nurses indicate dissatisfaction with the EHR design and cumbersome electronic processes
(Sockolow, Liao, Chittams, & Bowles, 2012; Stevenson, Nilsson, Petersson, & Johansson, 2010), they view the
EHR and the data generated as an opportunity to improve care, safety, quality, and coordination (Cipriano et al.,
2013), as well as a tool to study appropriate nurse staffing and to gauge or predict staffing needs (Beck et al.,
2013; Harper, 2012b).
The work of the Nursing Practice Committee (NPC) of the Missouri Nurses
Association (MONA) included identifying areas of interest to direct care nurses.
One identified interest area was the EHR, which was seen by nurses as both a
benefit and a source of considerable frustration. Furthermore, nurses were
challenged to articulate their concerns due, in part, to the fact that there was no
available taxonomy to describe EHR-related difficulties. This article begins to
articulate EHR concerns of Missouri nurses. Realizing that these concerns
transcend state boundaries, the MONA NPC decided to share their
recommendations with a broader nursing audience with the hope that they would
increase participation of all direct care nurses in EHR, vendor, and Health
Information Technology (HIT) department decisions and problem solving. In this
...nurses were
challenged to
articulate their
concerns due, in
part, to the fact
that there was no
available taxonomy
to describe EHR-
related difficulties. The Model
Direct care nurses,
at their core, are
risk managers.
They attach
meaning to what is
and anticipate
‘what might be.’
HIT and the
electronic
documentation of
nursing care
directly influence
patient safety.
Committee Reflections and Recommendations for Improving Documentation
The investigation of
EHR-associated
medication
administration
article, we share the reflections and recommendations of MONA nurses with direct care nurses and HIT
communities across the nation and around the world.
The goals of this article are to add to the EHR literature by categorizing views of
nurses as expressed by members of the MONA NPC and to enhance the computer
vocabulary of all nurses, empowering them to voice their EHR concerns to IT staff
and vendors and to take their places at the table when health and nursing-related
IT decisions are being made. In this article, we will describe the experiential-
reflective reasoning and action model used to accomplish these objectives; share
committee reflections and recommendations for improving both documentation
and documentation technology; and conclude by encouraging nurses to consider
how they can develop their documentation and informatics skills.
We used an experiential-reflective reasoning model, one that leads to action, to accomplish our purpose. This
model includes consideration of participants’ context, experience, reflection, action and evaluation. This
experiential-reflective reasoning model has been incorporated into Jesuit pedagogy for more than 450 years.
Within nursing, the Jesuit model has been used as a basis for transformative change (Pennington, Crewell,
Snedden, Mulhall, & Ellison, 2013). It is analogous to the learning theory and the change/action research methods
identified by Kurt Lewin (Atherton, 2013; Smith, 2001). We used this model to categorize the experiences of the
members of the MONA Nursing Practice Committee related to their use of the EHR, to reflect upon these
experiences, and to draw up a set of recommended actions.
We reflected and articulated direct care nurses’ concerns regarding the EHR. We
involved direct care nurses in this initiative because they plan care used to
address the clinical judgments/diagnoses flowing from a nursing assessment and
provide care to individuals and/or families. The care itself is designed, through this
planning process, to achieve the desired outcomes (American Nurses Association
[ANA], 2010; Shake, n.d.).
Direct care nurses are bedside nurses; they include generalists, advanced practice registered nurses, care
coordinators, visiting nurses, public health nurses, camp nurses, and school nurses. In brief, they are found in any
and every setting where nurses practice. Direct care nurses, at their core, are risk managers. They attach meaning
to what is and anticipate ‘what might be’ (Meyer & Lavin, 2005). When they anticipate risk, they conduct
surveillance, intervene when necessary, and document not only their risk prevention findings/observations, but
their reasoning and clinical judgments, interventions, patient responses and outcomes.
HIT and the electronic documentation of nursing care directly influence patient
safety. This is because nursing documentation facilitates real-time communication
among all healthcare providers and because electronic documentation allows for
its study in proportions never before attempted. If patient safety is to be
optimized through EHR use, effective collaboration between nurses and HIT staff
is needed, along with greater clarity of the patient safety perspective that direct
care nurses offer.
The reflections and recommendations described in this section are not research findings, but rather reports of the
experiential/reflective thinking of the committee, categorized under the headings of both medication safety, and
direct care nursing documentation and standards of practice. It is from these reflections that recommendations
flow.
Medication Safety
NPC members focused primarily on medication safety, with special attention to the
prevention of errors and adverse events. They approached the discussion by
following the four categories used to organize medication error prevention
strategies in the Agency for Healthcare Research and Quality (2012) report. The
Nursing Practice Committee felt that the system, as implemented within the EHR,
is weighted toward maximizing the safety of the prescribing, transcribing, and
errors is a ripe area
for nursing
research and/or
nurse-led quality
improvement
studies.
In each of these
examples, the data
were already
contained within
the EHR; they
simply needed to
be connected in a
nurse-and-patient-
safety-sensitive
manner.
dispensing categories (see Table 1). The table indicates that, of the citations
retrieved, only 35 were devoted to medication administration. Of these, only two
included the word nurse or nursing in the title (Debono et al., 2013; Yuan, Finley,
Long, Mills, & Johnson, 2013). There were no nurses as first authors among the
35 citations dealing with medication administration, nor were there any citations
from nursing journals. The investigation of EHR-associated medication
administration errors is a ripe area for nursing research and/or nurse-led quality
improvement studies.
Table 1. Distribution of Citations Retrieved from PubMed Central Database on September 28, 2014
Search string: EHR AND
prevention AND
medication error AND…
Number of citations
retrieved
More recent and last
citation publication
date
Prescribing 201 2004 - 2014
Transcribing 9 2010 - 2014
Dispensing 69 2005 - 2014
Administering 35 2005 - 2014
Total number of citations
and overall range
314
2005 - 2014
The NPC further recommended that all four categories of prescribing, transcribing, dispensing, and administering
(thus including the nursing-sensitive medication administration category) be digitalized and synchronized in the
EHR. Such an action would combine bar code medication administration technology at the point of care with real-
time medication surveillance of therapeutic goal attainment, enhanced adverse drug-event alerts, and adverse
event-surveillance information. In other words, if bar code data could be used to do more than identify the patient
and report medication administration doses, the additional synchronization of information would broaden the scope
of the medication-administration patient safety zone. This would give nurses more efficient access to information
which the nurse actually uses when administering medications. Additional information, triggered by the bar code,
might help the nurse to:
Identify and evaluate the appropriateness of the drug dose and route, given the drug’s specific therapeutic goal
Respond to an enhanced, real-time medication contraindication/drug interaction check with the EHR, by linking
the drug on the same screen with the most recent, clinically relevant laboratory values
For example, if a low serum potassium value were to appear, it would prompt the nurse to request a supplement
for the patient receiving a thiazide. It is important to note that the nurse currently takes these steps manually in a
time-consuming process, searching for the potassium values while preparing the drug for administration. The
electronic process being recommended is both more efficient and safer.
Electronic medication records (eMARs) should also include trending of medications along with clinically relevant
laboratory values. Insulin administration in the eMAR should be trended with the most recent plasma glucose and
serum potassium levels in a single view, so as to keep busy nurses from having to retrieve the labs from another
flow sheet in the EHR.
In each of these examples, the data were already contained within the EHR; they
simply needed to be connected in a nurse-and-patient-safety-sensitive manner.
Programming of drug administration processes at the point of patient contact, with
strategically placed tips and alerts, might lessen medication errors significantly.
We authors support informatics research that moves in this direction. We also
offer the following additional medication safety recommendations:
Improve user friendliness (screen size, font size, adequate LED lighting for use
in darkened rooms) of handheld devices used to bar code scan medications
Build in efficient and timely access to laboratory results for all medication
providers (physicians, advanced practice registered nurses [APRN], pharmacists,
and other direct care nurses).
Use of non-
standard materials
will cause
documentation to
appear as if nurses
are not meeting
patient
education/health
promotion
standards.
...it is imperative
that specialty-
specific nurses
become involved in
the selection and
updating of
computer-
generated, patient-
education materials
to ensure the
evidence base and
the
appropriateness of
all materials.
...the electronic
health record
should allow
providers to
manually order or
sort the problem
list.
Finally, we encourage careful consideration of policies governing the use of pharmacy technicians in dispensing
medications without direct pharmacist supervision. Boards of Nursing and Pharmacy may want to take up this
consideration from a regulatory or statutory viewpoint. EHRs need to reflect the credentials of the person
dispensing and administrating the medications to compare medication error rates between and among licensed
and unlicensed personnel.
Direct Care Nursing Documentation and Standards of Practice
Appropriate quality care comparisons among and between providers and practices can only be made when
standardized processes and products are used. This section will explore three aspects of the patient safety
implications of direct care nursing documentation and its unique characteristics from three aspects, including
standardization of evidence-based care processes, transparency of the nursing process, and development of an
electronic workflow tool to standardize and improve communication.
Standardization of evidence-based care processes. The NPC recommended
standardization of evidence-based care processes, including patient educational
materials and actions plans, within and eventually across the care setting.
Appropriate quality care comparisons can only be made when such standardized
processes and products are used. The operational phrase is ‘when standardized
processes and products are used.’ If nurses or nurse practitioners use their own
materials and do not use, for example, the EHR-generated patient education
materials, then they are at a disadvantage when electronic comparisons within
and between institutions are made. Use of non-standard materials will cause
documentation to appear as if nurses are not meeting patient education/health
promotion standards.
Registered nurses, including APRNs, may defend themselves by saying that their
own personal materials are the most current and most evidence-based. If this is
so, then it is imperative that specialty-specific nurses become involved in the
selection and updating of computer-generated, patient-education materials to
ensure the evidence base and the appropriateness of all materials. In addition,
documents generated by the EHR must be written clearly and simply, in keeping
with sound health-literacy and evidence-based patient education strategies and
tools Harvard School of Public Health (n.d.). Nurses may also voice concerns
about newer electronic documentation methods interrupting workflow, in which
case they need to become personally involved in workflow design with vendors or
with IT department personnel.
Some may object to the notion of ‘standardized’ care processes, incorrectly thinking it eliminates individualized
care. In contrast to this misperception, it is important to recognize that evidence-based practices and
standardization of care processes help to assure that the quality of care is optimized for each individual patient.
The premises underlying evidence-based practice and standardized care do not negate, but rather heighten,
individualization of care, including consideration of personal beliefs, values, and individual preferences. In brief,
evidence-based practice and the standardization of care processes enhance the trust patients have in nurses to
consistently function on behalf of their best interest.
Prioritization of diagnoses and transparency of the nursing process. The Nursing Practice Committee
recommended that nurses make the nursing process more transparent in the EHR for each patient problem
requiring nursing care. The Committee also recommended that nurses properly prioritize patient problems in their
documentation.
Proper prioritization of diagnoses and a more transparent process are two
methods of evaluating nursing documentation. The American Health Information
Management Association indicates the electronic health record should allow
providers to manually order or sort the problem list (AHIMA Workgroup, 2011).
Analogously, nurses need to have the ability to manually order or sort by priority
the diagnoses that drive their interventions.
When
documentation is
poor it is likely that
both human and
technologic
improvements are
needed.
Transparency refers to the clarity of the record for its users. Transparency, in more recent times, has come to
mean the open sharing of information. For purposes here, we define electronic health record transparency as clear
and open sharing of information among providers and with patients. While providers using the EHR have access to
information inserted by interdisciplinary team members, access to this information is not always intuitive, nor is its
presentation always clear. Systems today do provide patients with electronic access to limited information in their
EHRs. However, it is possible that even greater information sharing in the future will further improve the quality of
care (Delbanco et al., 2010; Delbanco, et al., 2012).
Development of an electronic workflow to standardize and improve communication. Additionally, the
Nursing Practice Committee recommended that the nursing process steps be researched and developed into an
abbreviated communication tool, one that would describe and prioritize each individual patient problem for use
during handoff at change of shift and also when documenting planning of care during admission, transfers, and
discharges. The NPC suggested that nurses apply ANA nursing practice and documentation standards within the
EHR using the nursing process model illustrated in the Figure.
Figure. Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation
Model
A simple, electronic workflow helps standardize and improve communication of direct
care in keeping with the ANA documentation standards (2010), as in the following
focused-care example.
Assessment: Data provide information for nurses to arrive at specific clinical
judgments (diagnoses/problems).
Diagnoses/Problems/Clinical Judgments: Appropriate outcome identification,
planning, and implementation of interventions are not random actions, but are
actions that are assessment-and-diagnostic-specific.
Outcome Identification and Planning: In these two standards, nurses specify
the intervention(s) to be used to achieve the desired outcomes, both process
outcomes and clinical outcomes.
Implementation: Engage the individual/family/community/population in care
planning and on the implementation of interventions. Conduct on-going vigilance
and act to prevent or to reverse movement toward outcomes that are undesired.
Initiate rescue, as needed.
Evaluation: Document patient outcomes and make summative
statement/analysis, e.g., condition stabilizing/worsening. Continue to modify plan
to achieve desired process and clinical outcomes.
The purpose of nursing documentation is to record nursing care provided and patient responses. The old adage, ‘If
it wasn’t charted, it wasn’t done,’ still holds today. Because the current standard of care is the nursing process, the
steps in the nursing process need to be evident in nursing documentation. If the process is documented, then the
practice standard will be judged as ‘met.’ If the process is not documented, then the practice standard will be
considered ‘not met.’ This standard holds true for registered nurses at all levels, whether nurses are documenting
in EHR or on paper health records.
We authors find human-machine interaction to be interesting. When there is an
issue with documentation, those closest to the world of informatics are quick to
exculpate the EHR by saying it was never intended to fill a gap in practice. On the
other hand, those closest to the clinical world are quick to exculpate themselves
by blaming one or more technical features of the EHR. Reality most likely lies
somewhere in the middle. When documentation is poor it is likely that both human
and technologic improvements are needed.
It may be that standardization of care processes, including clinical decision-support processes, becomes more fully
appreciated as the number of Doctor of Nursing Practice (DNP) graduates increase. These graduates are prepared
to use new quality improvement technologies; organize and analyze the evidence that flows from their own
practice; and compare their practice parameters against those of others. The following paragraph provides an
overview of DNP clinical projects designed to improve patient outcomes or reduce patient risk by improving care
processes.
Examples of DNP projects that incorporated clinical decision-support processes include: a) establishing criteria for
evaluating provider compliance with amiodarone guidelines in primary care (Dixon, Thanavaro, Thais, & Lavin,
2013); b) addressing therapeutic or clinical inertia in the management of patients with diabetes (Apsey et al.,
2013; Mackey et al., 2014); and (c) decreasing HbA1C by building confidence in patient ability to select correct
portion sizes and complete weekly exercise plans (Beckerle & Lavin, 2013). APRNs, and especially DNP graduates,
Clinical decision
support (CDS)
information
depends on real
time data.
Committee Reflections and Recommendations for Improving Documentation Technology
...structured,
electronic
documentation is
more closely
associated with
quality patient
outcomes in
primary care than
free text or
dictated
documentation.
know that the ability to take advantage of EHR data to improve patient care first requires the proper entry of
process and outcome data in the record.
Appropriate timing of nursing documentation, both real time/synchronous and late charting/asynchronous
documentation, requires that nurses have access to and use the EHR at the point of care. Nurses use both
synchronous and asynchronous methods to document care . Perhaps when voice activated, natural language
processing methods are further developed and better integrated into the EHR, all nursing documentation will be
synchronous.
Clinical decision support (CDS) information depends on real time data. Triggering
an alert for sepsis is only beneficial if the alert comes as soon as the system
inflammatory response system (SIRS) criteria are met. If the vital signs are
written on paper and entered later, the alert is delayed and patient safety is
impaired.
Continued research is needed in basic nursing care of the ill patient and its documentation (Englebright, Aldrich, &
Taylor, 2014; Van Achterberg, 2014). Documentation studies indicate that factors to promote diagnostic reasoning
and accuracy have been identified. These factors include use of problem, etiology, and signs/symptoms (PES)
structure; computerized aids (e.g. diagnostic specific scales); and standardized care plans (Müller-Staub & Paans,
2011; Paans, Nieweg, van der Schans, & Sermeus, 2011; Paans, Sermeus, Nieweg, Krijnen, & Schans, 2012).
Other methods to improve documentation include nursing documentation audits, use of safety checklists in
surgery, and nursing diagnostic-specific checklists (Mykkänen, Saranto, & Miettinen, 2012; Treadwell, Lucas, &
Tsou, 2014). Researchers should work closely with EHR vendors and terminology developers to be assured that
tools with known validity and reliability are correctly incorporated into the clinical workflow. These scales not only
meet nursing and hospital system standards but are increasingly being incorporated into big data and population-
health management.
Comparisons of physician documentation suggest that structured, electronic
documentation is more closely associated with quality patient outcomes in primary
care than free text or dictated documentation (Linder, Schnipper, & Middleton,
2012). On the other hand, unintended consequences may flow from what a clinical
ethicist calls EHR quality and documentation pitfalls. Examples include “copying
and pasting data from day to day without proper evidence of verification,
authorship ambiguities, inadvertent inclusion of un-obtained data in templated
notes, ambiguous history and physical examination findings, failure to review
prepopulated data, inadequate discharge summaries” (Bernat, 2013, p.1057).
Each of these issues may be prevented or addressed by discussion and exchange of information between the
provider, whether physician or nurse, and the vendor and/or IT department. Most vendors provide software with a
variety of options for each assessment parameter (e.g., yes, no [not present], no [NA], or deferred). Yet, well-
intended but clinically inappropriate IT decisions may be made. For example, in an attempt to save electronic
memory/space, a system may be designed to include ‘only’ a single yes/no option for each assessment parameter.
In such cases, the EHR nurse/physician on the next shift -- or much later when a case is presented in court -- does
not know if a recorded ‘no’ means that the parameter was assessed and found to be negative, or was not assessed
because it was not applicable, or was deferred.
When clinicians identify problems, such as ambiguous yes or no options, they are encouraged to correct them by
explaining clinical and legal consequences of such decision-making to IT department staff or to healthcare system
executives. Other technology issues may also need to be voiced to vendors.
In the paragraphs below, we will first consider efficiency and EHR technology concerns. Then we will offer HIT and
nursing practice recommendation.
Efficiency Concerns Related to the Use of EHR Technology
A time and motion
study addressing
nurses’ work in the
acute care setting
found that
collecting, entering,
and accessing data
used a large
portion of nurses’
time.
...a well-
constructed EHR
also reflects
accurately how
nurses think
(assess), arrive at
clinical judgments
(diagnose), identify
outcomes, plan,
intervene and
evaluate care.
Efficiency in the delivery of healthcare is defined as “avoiding waste, including waste of equipment, supplies, and
ideas” (Institute of Medicine, 2001, pg 6). Several studies have documented the lack of efficiency in current EHR
documentation practice.
A time-and-motion study of resident physicians' note-writing practices using an EHR revealed high fragmentation
in clinical work (Mamykina, Vawdrey, Stetson, Zheng, & Hripcsak, 2013). Activities that interrupted documentation
included: phone calls, patient requests, and frequent transitions between various types of documentation
modalities. Researchers suggested that physicians rely on synthesis rather than composition to write progress
notes. Newer technologies that support synthesis are exemplified by highlighting and thus capturing single words
or phrases from the chart to construct a new note descriptive of the patient at the current point in time. Another
technology would be use of the ‘ready selection of clinically relevant trend lines’ to indicate the patient's current
clinical status. Research is needed to compare the quality of such charting and to determine if it is less vulnerable
to fragmentation than current charting methods. This research needs to include study of the documentation by
both direct care nurses and physicians.
A time and motion study addressing nurses’ work in the acute care setting found
that collecting, entering, and accessing data used a large portion of nurses’ time.
This resulted in in considerably less nursing time available for patient care
(Hendrich, Chow, Skierczynski, & Lu, 2008).
A recent hospital-based study by Englebright et al. (2014) developed a definition of basic nursing care
documentation for the adult patient and integrated it into an EHR. The researchers concluded that this newer
method minimized or eliminated documentation that did not directly support patient care. These investigators
recommended use of alternative options for recording non-patient-care-related information and use of EHR
technology to help nurses document and communicate basic care elements.
The Nursing Practice Committee of the Missouri Nurses Association is committed to efficiency in the provision of
care. These nurses recognize that efficiency, including efficient capture of meaningful data, helps to translate
information and to communicate nursing-based knowledge to other members of the healthcare team, thus
improving patient safety and care quality. The MONA Nursing Practice Committee has recommended:
Ease of access and availability to computer devices in patient rooms. Emphasis should be on positioning
of the computer to augment the engagement of the nurse and the patient as partners in care. Because no single
device will work in all care areas, nurses should consider multiple types of computer device options. The number
of devices available should be contingent upon the number needed to cover high volume times of day.
High reliability/consistency when accessing/using computers on wheels. Variables to consider include
quality of the …