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When it comes to a patient’s stay at a hospital, health clinic or facility,
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When it comes to a patient’s stay at a hospital, health clinic or facility, there are many things that are now being done via the electronic health records (EHRs). Nursing considerations that can be highlighted in the electronic health records include, medication administrations, nursing assessments, diagnosis, and plan of care. For nurses, using the electronic health records can help guide nurses with their charting and documentation and also making it easier to communicate to providers about their patients. Some actions that can be taken to enhance the visibility and recognition of nursing contributions could be, having an option to highlight important information about the patient or their care, making it easier to identify in the chart. Another action that could be taken is making it possible to read a comment left behind by a nurse, provider, or healthcare worker by just hovering over it. This could save some time when looking at a patient’s chart. Some best practices that I would suggest to nursing professionals to adopt in order to streamline processes, reduce documentation burden, and enhance patient outcomes would be to cluster their care. Clustering care for patients could save nursing professionals time when it comes to assessing their patient, administering medications, and talking to the patient’s about any questions or concerns. Another best practice that nursing professionals could implement to reduce documentation burden is to document when you are assessing a patient. This will help with the feeling of having too much documentation to do by documenting in real time and not waiting until the last minute to finally document on all of your patient’s and feeling like it’s too much. Documenting in real time can also help the patient feel more comfortable with the nurse and enhance the patient’s outcome by having a thorough assessment of the patient and getting it in the chart before forgetting.
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Non-electronic nursing intervention can significantly impact patient outcomes, leading to gaps in care, delayed treatments, and compromised safety. Nurses may prioritize urgent patient needs over documentation, such as providing epinephrine or other medications in emergency departments, rather than documenting every procedure in the EHR. Nurses in complex cases with multiple treatments may struggle to record all actions, such as in intensive care units where immediate resuscitation is crucial for patient survival. Technology issues or failure of Electronic Health Record systems can also hinder recording, leading to manual documentation or directing attention to patients instead of electronic documentation. Nurses must ensure timely and accurate interventions to ensure patient survival. In my clinical practice at my Saudi university, I observed nurses not documenting nursing steps manually due to emergencies. This was particularly problematic during code blue events, where immediate life-saving operations were crucial. To mitigate this, healthcare organizations can implement post-event documentation protocols, requiring immediate documentation after resolving the emergency. The assistance of scribes or documentation assistants during high pressure ensures precision and timeliness, ensuring excellent patient care quality. Implementing a robust Electronic Health Record (EHR) system with built-in resilience and redundancy reduces the risk of system breakdown or technological limitations (Shaikh et al. 2022).
Healthcare institutions can enhance nursing recognition and visibility by providing continuous training and education, emphasizing electronic documentation and standardized terminology, and enhancing interdisciplinary collaboration between nursing informatics, IT professionals, and bedside nurses. Performance metrics can evaluate the quality and efficiency of documentation and the impact of nursing interventions on patients using EHRs. Nurses can improve documentation practices and patient care delivery through standardized processes, inter-professional collaboration, mobile technology, universal adoption of protocols, and integration of clinical decision support tools into EHRs. Continuous participation in quality improvement initiatives can identify flaws in the documentation process and replace them with a coordinated workflow solution, ultimately improving patient care.
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