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P029
Implementation of a Toolkit to Improve Documentation Practices and Nurse Satisfaction with Electronic Health Record Usability - A Quality Improvement Project
Purpose: The purpose of this quality improvement (QI) project was to implement the ECRI safe documentation practices toolkit on an acute-care medical-surgical unit to improve the integrity of nursing documentation while using the copy-paste functionality (CPF) and nurse satisfaction levels with electronic health record (EHR) usability.
Background/significance: In the dynamic realm of health care, where precision and efficiency intersect, the importance of accurate and timely nursing documentation is paramount. EHRs were implemented within healthcare facilities as a method to enhance safety culture and quality of care initiatives. However, despite how they have innovated health care and streamlined data entry, EHRs can contribute to new, unanticipated safety problems for healthcare organizations such as documentation inaccuracy. With increasing documentation requirements supplied by regulatory agencies, nurses often rely on workarounds to improve their efficiency while documenting within the EHR. One such workaround frequently utilized by nurses is CPF, which improves documentation efficiency for nurses during their shift. However, CPF is a double-edged sword when used; it can increase efficiency but may jeopardize the veracity of health records. When workarounds become an inherent part of an EHR, nurses often feel decreased satisfaction with the usability of an EHR and note difficulty in integrating this technology into their own workflow further decreasing their efficiency.
Methods: The ECRI Institute’s toolkit was used to create a new policy on documentation practices and CPF use in the EHR. Asynchronous educational sessions were provided to nursing staff on using CPF safely when documenting. To measure documentation integrity with CPF, audits of a random selection of EHRs were conducted using the ECRI Institute’s copy-paste audit log pre- and post-toolkit implementation. A 23-item Likert scale survey, the electronic health record satisfaction survey (EHRNS), was administered to a convenience sample of 13 nurses pre- and post-toolkit implementation to measure nurse satisfaction levels. Quantitative data was analyzed using a chi-square test of Homogeneity and a Wilcoxon signed rank test.
Evaluation/outcome: The implementation of the ecri safe documentation practices toolkit was shown to have a statistically significant impact (χ2(1) = 17.620, p < .001) on the integrity of nursing documentation within the EHR. However, there was no statistically significant improvement (z = -.548, p = .584) in nurse satisfaction with the usability of the EHR during the same period.
Conclusions: This QI project demonstrates that the use of the ECRI toolkit is a successful method that hospitals can use to improve the safety of documentation practices that utilize CPF.
Background/significance: In the dynamic realm of health care, where precision and efficiency intersect, the importance of accurate and timely nursing documentation is paramount. EHRs were implemented within healthcare facilities as a method to enhance safety culture and quality of care initiatives. However, despite how they have innovated health care and streamlined data entry, EHRs can contribute to new, unanticipated safety problems for healthcare organizations such as documentation inaccuracy. With increasing documentation requirements supplied by regulatory agencies, nurses often rely on workarounds to improve their efficiency while documenting within the EHR. One such workaround frequently utilized by nurses is CPF, which improves documentation efficiency for nurses during their shift. However, CPF is a double-edged sword when used; it can increase efficiency but may jeopardize the veracity of health records. When workarounds become an inherent part of an EHR, nurses often feel decreased satisfaction with the usability of an EHR and note difficulty in integrating this technology into their own workflow further decreasing their efficiency.
Methods: The ECRI Institute’s toolkit was used to create a new policy on documentation practices and CPF use in the EHR. Asynchronous educational sessions were provided to nursing staff on using CPF safely when documenting. To measure documentation integrity with CPF, audits of a random selection of EHRs were conducted using the ECRI Institute’s copy-paste audit log pre- and post-toolkit implementation. A 23-item Likert scale survey, the electronic health record satisfaction survey (EHRNS), was administered to a convenience sample of 13 nurses pre- and post-toolkit implementation to measure nurse satisfaction levels. Quantitative data was analyzed using a chi-square test of Homogeneity and a Wilcoxon signed rank test.
Evaluation/outcome: The implementation of the ecri safe documentation practices toolkit was shown to have a statistically significant impact (χ2(1) = 17.620, p < .001) on the integrity of nursing documentation within the EHR. However, there was no statistically significant improvement (z = -.548, p = .584) in nurse satisfaction with the usability of the EHR during the same period.
Conclusions: This QI project demonstrates that the use of the ECRI toolkit is a successful method that hospitals can use to improve the safety of documentation practices that utilize CPF.
Learning Objective
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Speaker
Arielle St. Romain, DNP, RN, CNEcl
Specialties
General
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