Nursing Informatics in Documentation

      “Data that are captured in a standardized, automated fashion can help in identifying trends and benchmarking, which are powerful tools in identifying areas for process improvement and making the case for increased resource allocations,” Clayton says.

      The new healthcare-delivery model revolves around the electronic health record (EHR), a one-stop documentation system that fosters safer handoffs, communication between providers, informed decisions, accurate discharge plans, and other benefits. Aggregated across multiple healthcare organizations, patient data can serve to pinpoint important healthcare trends and spawn system-wide ideas for cutting costs, improving efficiency, and managing chronic disease.

      In the past, computers in healthcare facilities have been used largely to capture nonclinical data such as room turnover times or total orthopedic cases, says Denise Downing, RN, MS, a clinical informatics specialist for the Association of periOperative Registered Nurses. But with new systems focused on patient care, “now you can drill down and see what kind of orthopedic cases were done; the patient population in which a particular procedure is done; the positioning aids that were used, which ties into pressure ulcer outcomes; and comorbidities such as diabetes,” she says. “This will all provide data for development of best practices.”

      In part because electronic health records can require that each section of a document be filled out, patient safety also can be improved, says Patricia Hinton Walker, RN, PhD, FAAN, PCC, vice president for nursing policy at the Uniformed Services University of the Health Sciences in Bethesda, Md. “If I have to check off every box before I sign off, I will not miss an allergy,” she says. “In the paper record it could be unreadable or forgotten or put somewhere people don’t look.”

      Electronic records also can include tools to support clinical decision-making. “All of us can’t be as up on every single diagnosis or the interaction of every drug,” Hinton Walker says, but technology can keep that information handy. “It’s not going to be right there at the front of my brain, but it is there at my fingertips.”

      Although the benefits of digitizing healthcare records and processes had long been recognized, President George W. Bush gave the national effort a boost in 2004 by establishing the Office of the National Coordinator for Health Information Technology and setting 2014 as a target date for the widespread adoption of electronic health records. Since then, the Obama administration has endorsed the 2014 timeline and added funding, as well as specific interim steps to get there, Hinton Walker says.

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