Nurse Educator Vol. 40, No. 1, pp. 7-9 Copyright * 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Educator
Technology Corner
Evaluating Senior Baccalaureate Nursing Students’ Documentation Accuracy Through an Interprofessional Activity Gina L. Schaar, DNP, RN Gabriela Mustata Wilson, PhD, MSc
T
oday’s health care system is increasingly complex and involves synergy between many health care professionals from varying disciplines. The electronic health record (EHR) allows health care providers to share information and work collaboratively to document and exchange information across the continuum of care. The EHR not only has the potential to improve the overall quality of health care delivery by making patients’ health and medical information readily accessible, but is also pivotal in leveraging improved quality of patient care, care coordination, and fostering more accurate diagnosis and health outcomes.1-3 Studies show the EHR facilitates and adds value to interprofessional communication.4-6 However, to achieve the desired communication goals, the end users (providers) must interact effectively with the EHR to ensure documentation accuracy.7 Complete, concise, and accurate EHR documentation not only helps ensure patient care quality, but it also lessens the burden of legal issues stemming from incomplete medical records.8,9 Failure to meet documentation standards, however, can undermine patient safety and create EHR inconsistencies that may be scrutinized in legal proceedings where the standard of care is being questioned.10 Despite the acknowledged benefits of accurate EHR documentation, studies describing undergraduate nursing students’ EHR documentation accuracy are absent. Our task as educators is to ensure our students are equipped with the skill set needed to accurately document in the patient’s medical record. This article reports senior-level nursing students’ real-time docuAuthor Affiliations: Assistant Professor, Nursing (Dr Schaar), Assistant Professor, Health Informatics (Dr Mustata Wilson), College of Nursing and Health Professions, University of Southern Indiana, Evansville. Dr Mustata Wilson contributed equally to this work. The authors declare no conflicts of interest. Correspondence: Dr Schaar or Dr Mustata Wilson, 8600 University Blvd, Evansville, IN 47712 ([email protected]; [email protected]). Published ahead of print: August 22, 2014 DOI: 10.1097/NNE.0000000000000079
Nurse Educator
mentation accuracy as recorded in an academic EHR during a high-fidelity (HF) obstetrical simulation. This study was designed to be an interprofessional educational (IPE) activity with senior undergraduate nursing and health administration (HA) students.
Methods This pilot study was conducted during an IPE activity involving senior undergraduate baccalaureate nursing (n = 36) and HA students enrolled in a required health informatics course (n = 23). Prior to the IPE activity, university institutional review board approval was obtained. Nursing students, all traditional prelicensure students, enrolled in the maternal neonatal course, participated in a postpartum hemorrhage simulation involving a non–English-speaking mother. All HA students observed the simulation to familiarize themselves with the clinical scenario. Nursing students were presented with 4 learning objectives: (1) identify early signs and symptoms of postpartum hemorrhage and provide appropriate nursing care, (2) recognize challenges associated with providing emergent nursing care to a non–English-speaking patient, (3) identify legal issues nurses face when obtaining an informed consent from a non–English-speaking patient, and (4) recognize the importance of EHR documentation accuracy. The HA students’ objectives were to increase informatics knowledge and skill set, provide a real-life EHR charting experience, and analyze patient information and clinical data accuracy. The shared learning objectives for both groups were to collaboratively verify documentation accuracy while promoting interprofessional communication and to showcase the importance of documentation accuracy. Of the 36 nursing students, 4 actively participated in the simulation assuming the registered nurse role, and 2 were direct observers in the simulation center. The remaining 30 nursing students and all 23 HA students assumed the observer role and viewed the simulation via the live video feed. Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
7
Participation in the simulation, including EHR documentation, was a required classroom assignment, but analysis of student documentation was voluntary. All nursing students consented to have their documentation analyzed. The EHR platform used in this simulation was Cerner.11 Given the EHR preset template is not always able to capture an emergent event, students were asked to document pertinent data in the free-text box. The IPE activity began with an obstetrical simulation using an HF simulator. A split-screen view allowed all remote observers to simultaneously view the simulation and vital sign monitor readings. During the simulation, all nursing student observers and the nursing faculty member, serving as the content expert, documented pertinent patient information in the EHR. The faculty’s documentation served as the template against which the nursing students’ documentation was then compared. Prior to the simulation, nursing students completed a written assignment that addressed postpartum hemorrhage risk factors, pathophysiology, and treatment. Early in the simulation, the students learned the patient was a postpartum mother who could not speak or understand English. Initially, the patient was stable, but as the simulation unfolded, the patient’s vaginal bleeding increased significantly, and she became hemodynamically unstable. As the patient began to hemorrhage, the students identified quickly the need to use the simulated hospital translation line to explain the needed nursing and medical interventions. During the simulation, the students provided nursing care based on standing postpartum physician orders such as urinary catheter insertion and medication administration. At the completion of the simulation, the 23 HA students were assigned to 1 of 7 groups to analyze 4 to 5 nursing students’ documentation accuracy compared with the content expert. Key events from the content expert’s narrative were used to build keyword annotations that were then used to identify and extract like data from the individual student documentations. Students from both disciplines then came together to form interdisciplinary teams to discuss and critically review the documentation analysis completed by the HA students. Recognizing the HA students were not direct care providers, both disciplines worked collaboratively to ensure the keyword annotations were appropriate and relevant to the clinical simulation. Both nursing and HA faculty reevaluated the final key events compiled by the student groups and identified the following critical documentation themes: general assessment, vital signs, medications, nursing interventions, patient assessment changes, and language barrier. Using these critical themes, both faculty members assessed the accuracy of the data recorded by each individual student group and by all 7 groups. Data accuracy was dependent on the percentage of students/groups whose documentation matched the content expert. Using these data, mean accuracy was then calculated.
Results Thirty of 32 nursing students completed the EHR documentation. Two students, 1 direct student observer and 1 who viewed the simulation remotely, were unable to complete their documentation in the EHR because of computer-related issues. Based on the identified documentation themes, group data were then analyzed. The general assessment data ac8
Volume 40 & Number 1 & January/February 2015
curacy varied between 44% and 80%; vital signs, 15% and 94%; medications, 60% and 85%; nursing interventions, 59% and 88%; change in patient assessment, 40% and 77%; and language barrier, between 20% and 75%. The combined accuracy of the 7 groups for each of the documentation themes was as follows: general assessment, 67%; vital signs, 48%; medications, 71%; nursing interventions, 74%; changes in patient’s condition, 62%; and language barrier, 63%. More than 70% of students failed to document the reason the patient was being admitted to the hospital, and less than 30% documented the significant vital sign change that occurred as the patient began to hemorrhage. As this scenario involved a non–English-speaking patient, less than 40% documented this finding in the EHR. Yet, almost 90% of students accurately documented completion of nursing tasks that were carried out during the simulation such as urinary catheter insertion. Specifically under the medication theme, almost 90% of students’ documentation correctly reflected the time and type of medication being administered, yet less than 10% documented that the medication adverse effects had been explained to the patient.
Recommendations Based on the results obtained from this pilot study, it is evident that students should be given the opportunity to participate in real-time EHR documentation and that EHR-based exercises should be integrated in undergraduate nursing and health profession programs. Educators should emphasize the importance of active learning through simulation and EHR documentation, provide students feedback regarding their documentation accuracy, and highlight its value in direct patient care.
Conclusion The simulation proved to be both a valuable strategy for interprofessional learning and a means of promoting and assessing nursing students’ EHR documentation accuracy. In a position paper released by the American Medical Informatics Association, evaluating best practices was cited as being a critical component to effective EHR use.12 Although this study was based on a small number of nursing students, the results suggest that students need to be offered opportunities to practice their documentation skills and more importantly exercises in which their EHR documentation is evaluated for clarity, timeliness, and accuracy. In an era of health care in which patient safety is at the forefront, reimbursement dollars are closely linked to documentation, and medical litigation persists, EHR documentation accuracy is paramount.
References 1. HealthIT.gov. Benefits of electronic health records (EHR). 2012. Available at http://healthit.gov/providers-professionals/benefitselectronic-health-records-ehrs. Accessed April 25, 2014. 2. Kern LM, Barron Y, Dhopeshwarkar RV., Edwards A, Kaushal R. Electronic health records and ambulatory quality of care. J Gen Intern Med. 2013;28(4):496-503. 3. American College of Obstetricians and Gynecologists. Committee opinion: patient safety and the electronic health record (no. 472). 2010:1-3. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4. Reitz R, Common K, Fitfield P, Stiasny E. Collaboration in the presence of an electronic health record. Fam Syst Health. 2012; 30(1):72-80. 5. The Joint Commission. Facts about patient-centered communications. 2012. Available at http://www.jointcommission.org/ assets/1/18/Patient_Centered_Communications_7_3_12.pdf. Accessed April 26, 2014. 6. Green SD, Thomas JD. Interdisciplinary collaboration and the electronic medical record. Pediatr Nurs. 2008;34(3):225-240. 7. Effken J, Carrington J. Communication and the electronic health record: challenges to achieving the meaningful use standard. Online J Nurs Inform. 2011;15(2):555-558.
Nurse Educator
8. Clark JS, Delgado VA, Demorsky S, et al. Assessing and improving EHR data quality (updated). J AHIMA. 2013;84(3):48-53. 9. Austin S. Stay out of court with proper documentation. Nursing. 2011;41(4):25-29. 10. Austin S. Safe nursing practice. Nursing. 2008;38(3):35-39. 11. Cerner. Academic EHR. Available at http://www.cerner.com/ solutions/Education_and_Training/Academic_Education_Solution/. Accessed May 15, 2014. 12. Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc. 2013;20(e1):e2-e8.
Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
9
Nurse Educator
Technology Corner
Evaluating Senior Baccalaureate Nursing Students’ Documentation Accuracy Through an Interprofessional Activity Gina L. Schaar, DNP, RN Gabriela Mustata Wilson, PhD, MSc
T
oday’s health care system is increasingly complex and involves synergy between many health care professionals from varying disciplines. The electronic health record (EHR) allows health care providers to share information and work collaboratively to document and exchange information across the continuum of care. The EHR not only has the potential to improve the overall quality of health care delivery by making patients’ health and medical information readily accessible, but is also pivotal in leveraging improved quality of patient care, care coordination, and fostering more accurate diagnosis and health outcomes.1-3 Studies show the EHR facilitates and adds value to interprofessional communication.4-6 However, to achieve the desired communication goals, the end users (providers) must interact effectively with the EHR to ensure documentation accuracy.7 Complete, concise, and accurate EHR documentation not only helps ensure patient care quality, but it also lessens the burden of legal issues stemming from incomplete medical records.8,9 Failure to meet documentation standards, however, can undermine patient safety and create EHR inconsistencies that may be scrutinized in legal proceedings where the standard of care is being questioned.10 Despite the acknowledged benefits of accurate EHR documentation, studies describing undergraduate nursing students’ EHR documentation accuracy are absent. Our task as educators is to ensure our students are equipped with the skill set needed to accurately document in the patient’s medical record. This article reports senior-level nursing students’ real-time docuAuthor Affiliations: Assistant Professor, Nursing (Dr Schaar), Assistant Professor, Health Informatics (Dr Mustata Wilson), College of Nursing and Health Professions, University of Southern Indiana, Evansville. Dr Mustata Wilson contributed equally to this work. The authors declare no conflicts of interest. Correspondence: Dr Schaar or Dr Mustata Wilson, 8600 University Blvd, Evansville, IN 47712 ([email protected]; [email protected]). Published ahead of print: August 22, 2014 DOI: 10.1097/NNE.0000000000000079
Nurse Educator
mentation accuracy as recorded in an academic EHR during a high-fidelity (HF) obstetrical simulation. This study was designed to be an interprofessional educational (IPE) activity with senior undergraduate nursing and health administration (HA) students.
Methods This pilot study was conducted during an IPE activity involving senior undergraduate baccalaureate nursing (n = 36) and HA students enrolled in a required health informatics course (n = 23). Prior to the IPE activity, university institutional review board approval was obtained. Nursing students, all traditional prelicensure students, enrolled in the maternal neonatal course, participated in a postpartum hemorrhage simulation involving a non–English-speaking mother. All HA students observed the simulation to familiarize themselves with the clinical scenario. Nursing students were presented with 4 learning objectives: (1) identify early signs and symptoms of postpartum hemorrhage and provide appropriate nursing care, (2) recognize challenges associated with providing emergent nursing care to a non–English-speaking patient, (3) identify legal issues nurses face when obtaining an informed consent from a non–English-speaking patient, and (4) recognize the importance of EHR documentation accuracy. The HA students’ objectives were to increase informatics knowledge and skill set, provide a real-life EHR charting experience, and analyze patient information and clinical data accuracy. The shared learning objectives for both groups were to collaboratively verify documentation accuracy while promoting interprofessional communication and to showcase the importance of documentation accuracy. Of the 36 nursing students, 4 actively participated in the simulation assuming the registered nurse role, and 2 were direct observers in the simulation center. The remaining 30 nursing students and all 23 HA students assumed the observer role and viewed the simulation via the live video feed. Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
7
Participation in the simulation, including EHR documentation, was a required classroom assignment, but analysis of student documentation was voluntary. All nursing students consented to have their documentation analyzed. The EHR platform used in this simulation was Cerner.11 Given the EHR preset template is not always able to capture an emergent event, students were asked to document pertinent data in the free-text box. The IPE activity began with an obstetrical simulation using an HF simulator. A split-screen view allowed all remote observers to simultaneously view the simulation and vital sign monitor readings. During the simulation, all nursing student observers and the nursing faculty member, serving as the content expert, documented pertinent patient information in the EHR. The faculty’s documentation served as the template against which the nursing students’ documentation was then compared. Prior to the simulation, nursing students completed a written assignment that addressed postpartum hemorrhage risk factors, pathophysiology, and treatment. Early in the simulation, the students learned the patient was a postpartum mother who could not speak or understand English. Initially, the patient was stable, but as the simulation unfolded, the patient’s vaginal bleeding increased significantly, and she became hemodynamically unstable. As the patient began to hemorrhage, the students identified quickly the need to use the simulated hospital translation line to explain the needed nursing and medical interventions. During the simulation, the students provided nursing care based on standing postpartum physician orders such as urinary catheter insertion and medication administration. At the completion of the simulation, the 23 HA students were assigned to 1 of 7 groups to analyze 4 to 5 nursing students’ documentation accuracy compared with the content expert. Key events from the content expert’s narrative were used to build keyword annotations that were then used to identify and extract like data from the individual student documentations. Students from both disciplines then came together to form interdisciplinary teams to discuss and critically review the documentation analysis completed by the HA students. Recognizing the HA students were not direct care providers, both disciplines worked collaboratively to ensure the keyword annotations were appropriate and relevant to the clinical simulation. Both nursing and HA faculty reevaluated the final key events compiled by the student groups and identified the following critical documentation themes: general assessment, vital signs, medications, nursing interventions, patient assessment changes, and language barrier. Using these critical themes, both faculty members assessed the accuracy of the data recorded by each individual student group and by all 7 groups. Data accuracy was dependent on the percentage of students/groups whose documentation matched the content expert. Using these data, mean accuracy was then calculated.
Results Thirty of 32 nursing students completed the EHR documentation. Two students, 1 direct student observer and 1 who viewed the simulation remotely, were unable to complete their documentation in the EHR because of computer-related issues. Based on the identified documentation themes, group data were then analyzed. The general assessment data ac8
Volume 40 & Number 1 & January/February 2015
curacy varied between 44% and 80%; vital signs, 15% and 94%; medications, 60% and 85%; nursing interventions, 59% and 88%; change in patient assessment, 40% and 77%; and language barrier, between 20% and 75%. The combined accuracy of the 7 groups for each of the documentation themes was as follows: general assessment, 67%; vital signs, 48%; medications, 71%; nursing interventions, 74%; changes in patient’s condition, 62%; and language barrier, 63%. More than 70% of students failed to document the reason the patient was being admitted to the hospital, and less than 30% documented the significant vital sign change that occurred as the patient began to hemorrhage. As this scenario involved a non–English-speaking patient, less than 40% documented this finding in the EHR. Yet, almost 90% of students accurately documented completion of nursing tasks that were carried out during the simulation such as urinary catheter insertion. Specifically under the medication theme, almost 90% of students’ documentation correctly reflected the time and type of medication being administered, yet less than 10% documented that the medication adverse effects had been explained to the patient.
Recommendations Based on the results obtained from this pilot study, it is evident that students should be given the opportunity to participate in real-time EHR documentation and that EHR-based exercises should be integrated in undergraduate nursing and health profession programs. Educators should emphasize the importance of active learning through simulation and EHR documentation, provide students feedback regarding their documentation accuracy, and highlight its value in direct patient care.
Conclusion The simulation proved to be both a valuable strategy for interprofessional learning and a means of promoting and assessing nursing students’ EHR documentation accuracy. In a position paper released by the American Medical Informatics Association, evaluating best practices was cited as being a critical component to effective EHR use.12 Although this study was based on a small number of nursing students, the results suggest that students need to be offered opportunities to practice their documentation skills and more importantly exercises in which their EHR documentation is evaluated for clarity, timeliness, and accuracy. In an era of health care in which patient safety is at the forefront, reimbursement dollars are closely linked to documentation, and medical litigation persists, EHR documentation accuracy is paramount.
References 1. HealthIT.gov. Benefits of electronic health records (EHR). 2012. Available at http://healthit.gov/providers-professionals/benefitselectronic-health-records-ehrs. Accessed April 25, 2014. 2. Kern LM, Barron Y, Dhopeshwarkar RV., Edwards A, Kaushal R. Electronic health records and ambulatory quality of care. J Gen Intern Med. 2013;28(4):496-503. 3. American College of Obstetricians and Gynecologists. Committee opinion: patient safety and the electronic health record (no. 472). 2010:1-3. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4. Reitz R, Common K, Fitfield P, Stiasny E. Collaboration in the presence of an electronic health record. Fam Syst Health. 2012; 30(1):72-80. 5. The Joint Commission. Facts about patient-centered communications. 2012. Available at http://www.jointcommission.org/ assets/1/18/Patient_Centered_Communications_7_3_12.pdf. Accessed April 26, 2014. 6. Green SD, Thomas JD. Interdisciplinary collaboration and the electronic medical record. Pediatr Nurs. 2008;34(3):225-240. 7. Effken J, Carrington J. Communication and the electronic health record: challenges to achieving the meaningful use standard. Online J Nurs Inform. 2011;15(2):555-558.
Nurse Educator
8. Clark JS, Delgado VA, Demorsky S, et al. Assessing and improving EHR data quality (updated). J AHIMA. 2013;84(3):48-53. 9. Austin S. Stay out of court with proper documentation. Nursing. 2011;41(4):25-29. 10. Austin S. Safe nursing practice. Nursing. 2008;38(3):35-39. 11. Cerner. Academic EHR. Available at http://www.cerner.com/ solutions/Education_and_Training/Academic_Education_Solution/. Accessed May 15, 2014. 12. Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc. 2013;20(e1):e2-e8.
Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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