EHR Documentation: The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes

Nursing Administration Quarterly
Ann OʼBrienCatherine H Ivory

Abstract

The phenomenon of "data rich, information poor" in today's electronic health records (EHRs) is too often the reality for nursing. This article proposes the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care across the continuum. The principles consider the need to optimize nurses' documentation efficiency while contributing to knowledge generation. The nursing process must be supported by EHRs through integration of best care practices: seamless workflows that display the right tools, evidence-based content, and information at the right time for optimal clinical decision making. Design of EHR documentation must attain a balance that ensures the capture of nursing's impact on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes "death by data entry." In 2014, a group of diverse informatics leaders from practice, academia, and the vendor community formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our health care system moves toward reimbursement on the basis of quality outcomes and prev...Continue Reading

References

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Citations

Nov 30, 2016·Journal of Gerontological Nursing·Barbara St Marie, Paul Arnstein
Jan 4, 2017·Journal of Clinical Nursing·Gianfranco SansonFabio D'Agostino
Feb 24, 2017·Journal of Advanced Nursing·Fabio D'AgostinoMaurizio Zega
Mar 31, 2018·Computers, Informatics, Nursing : CIN·Laurel A Despins, Bonnie J Wakefield
Dec 6, 2019·The Journal of Nursing Administration·Jeffrey C BauerDale Richardson
Dec 14, 2018·International Journal of Nursing Knowledge·Chinma Stella Adereti, Adenike Ayobola Olaogun
Feb 8, 2019·Computers, Informatics, Nursing : CIN·Joni Padden
Jun 9, 2016·Computers, Informatics, Nursing : CIN·Heather Carter-TempletonAnn O'Brien
Mar 16, 2021·Journal of Nursing Scholarship : an Official Publication of Sigma Theta Tau International Honor Society of Nursing·Kay S LytleMariaelena Thibodeaux
Jun 20, 2021·Computers, Informatics, Nursing : CIN·Toni Phillips, Karen Baur
May 4, 2021·Computers, Informatics, Nursing : CIN·Min-Jeoung KangPatricia C Dykes

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