Explain how informatics can improve interdisciplinary communication and enhance quality.
Over the last few decades, healthcare facilities have increasingly adopted electronic health records (EHRs) to document and store patient information. With these changes, the field of informatics has become increasingly important, as staff are always looking to improve these systems to increase usability and patient outcomes. Nurses are trained to understand that if an intervention wasn’t documented, it may as well have never happened. There are so many reasons why accurate, efficient documentation is important to safety and quality of care and improving communication between healthcare staff is one of them. During a hospital stay, a patient will come into contact with a variety of healthcare professionals including nurses, doctors and other specialists. It is of utmost importance that these professionals are communicating the details of the patient’s care so that nothing is missed, and patient safety is preserved. Studies have shown that the use of a standardized electronic healthcare record is correlated with better patient outcomes than the use of freely dictated patient documentation (Lavin et al., 2015). This makes sense, considering that when staff are all using the same standardized documentation tool, that has narrowed down the points of most importance, there is less likelihood that information will be forgotten.
Discuss 2 burdens regarding nursing documentation via the electronic health record that you have experienced in clinical practice/rotations. What recommendations would you make to improve them?
This question is a little bit difficult to answer as a nursing student with very limited experience using an EHR. As an inexperienced user, I see certain things about the EHR that I kind confusing and not user-friendly. For example, when I work with patients who have been in the hospital for weeks or even months, I have a hard time getting information about important events or procedures that have happened since their admission. Yes, I could go back in time and read the provider notes from the beginning in chronological order, but I have thought that it would be very useful to have a patient timeline that shows the most important events and procedures that have happened during a hospital stay. I also have had a hard time being able to look at trends over time. For example, I have yet to figure out how look at just a patient’s blood pressure over the last month to look at trends without doing a lot of scrolling. Perhaps there are ways to get all of this information in an easily accessible manner, but I just haven’t learned how to do it yet. The nurses I have interacted with in clinical have always struggled with finding time to do charting, and there need to be changes made to help nurses complete this very important task. Decreasing nurse to patient ratios is the major way to do this, but improving EHR usability is another. Poor EHR usability has been correlated with high nurse burnout, and nurse burnout is correlated with poor patient outcomes (Nguyen et al., 2020). To decrease nursing burnout regarding EHR usability, I would recommend making computers readily available so that nurses could actively chart in the patient’s room while doing an assessment. I would also recommend increasing the amount of auto-filling fields, and pull down menus to decrease the amount of typing that the nurse has to do.
