For many of your more seasoned colleagues, this is not news. Even in my brief 35+-year nursing career, there have been so many variations. Each new theory was implemented to ensure that we communicated the care we gave. As the next one came along, remnants of the past method remained behind as if Hansel and Gretel were leaving breadcrumbs behind to find their way home. And just as we seem to get stuck with certain hairstyles or fashions after awhile, we find it difficult to let go of our favorite pieces of documentation theories.
It is part of that phenomenon where people say that they are just not going to learn that new fangled machine, device, and so forth. When motorized cars came on the scene, there were many who said horses and carriages were just fine and there were just not enough benefits to justify making such a financial investment or intellectual effort to learn a new skill. Everyone knows someone today who just "hates" computers and can not understand how you have time to be productive, if you are spending time blogging, tweeting, texting, and updating your social networking venues. The reality is that these leisure activities are adding pressure to use electronic means to do the heavy lifting of documentation. Looking at it from a historical perspective may help us transition more gracefully to its electronic state. Some questions come to mind as I think about documentation.
WHAT IS THE PURPOSE OF DOCUMENTATION?
In general, it is to record the quality of care provided to patients, the results of that care, and patients' continuing needs (Loeb, 1995). While Nightingale (1859) cited the importance of recording nursing observations, early documentation focused on proof that doctors' orders were implemented and that requisite care was provided. As reimbursement started focusing on documentation, it became a method to verify and justify nurses' actions.
WHO IS READING DOCUMENTATION?
Communicating with other members of the care team would seem the most logical use of documentation but is probably the least used. Oral reports and handoffs are probably more commonly used for this purpose. The entities reading documentation to verify the quality of care given include the following:
* Accreditation, certification, and licensure organizations
* Quality-assurance committees
* Peer-review organizations
* Payors
* Patients
* Lawyers
Each of these potential documentation reviewers has a different purpose but they are all looking for evidence that appropriate care was provided.
WHAT ARE SOME FORMATS OF DOCUMENTATION?
Not an exhaustive list, here are just some of the things we have tried:
* Source-oriented narrative record
* Problem-oriented medical record
* SOAP charting
* SOAPIE charting
* CBE method
* Focus charting
* Pie charting
* Computerized record keeping
The future is certainly the electronic medical record (EMR). While most of these are very expensive and complex systems, Clifford (2009) suggests that medical practices may be able to comply with much simpler systems. Implementing EMRs would not be so difficult if the settings were more similar and a standard system could be installed. However, "One size fits all" is a philosophy that healthcare organizations do not embrace. Still used today, Benjamin Franklin's model for the hospital may contribute to this viewpoint that each hospital is unique. Nance (2010) describes that the hospital's purpose is to accommodate physicians with the patient as the by-product of the arrangement. According to several speakers at the 57th AORN Congress, regardless of whether the U.S. Congress passes a bill, things are going to change with healthcare and this model may well be one of them. Making the best EMR decisions would be a difficult task in a stable environment, and no one would call the current environment stable.
Things do not remain the latest and greatest that long in today's rapidly changing technology revolution. With innovations potentially making your newly purchased EMR out-of-date, obsolete, or even irrelevant in as little as a week, this is no small challenge. Being nimble will quickly become the most sought after feature of an EMR.
The advice for purchase and implementation has not changed much over the last two decades. The names of the steps may be different and the process may have a new and improved name, but the principles are really the same.
* Have end users participate in all levels of the process. This includes the product-selection process. They may not know all the technical requirements, but this is a good place to start the education of the staff about what is coming and what needs to be done.
* Ask how the system will do things. The world is littered with facilities that ask whether a system had a particular feature, the vendor answered yes and when it came to implementation, it did not work as expected.
* Look at the workflow processes involved. Converting a poor manual system to an electronic version will most likely make it worse. This is the time to assess how things are done and make changes that improve the outcomes.
Following these guidelines may help you have a successful conversion to EMR. There is one other thing that can help. Experience is often our best teacher. If you have recently implemented a system or are in the process of making a decision or implementation, please share it with your colleagues in the form of an article for the journal or even a Letter to the Editor. Submissions are conveniently accepted online at http://www.editorialmanager.com and I am very happy to mentor authors.
Please feel free to forward your comments to me and the editorial board by writing us at Plastic Surgical Nursing, American Society of Plastic Surgical Nurses, 7794 Grow Drive, Pensacola, FL 32514 or send an e-mail to Candise Flippin at [email protected].
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