NUR 701 WA 2 with Update

What I Learned

 The world of healthcare is changing and so are the tools we use to care for patients.  The nature of documentation is a prickly one as there are so many different facets that require accurate notation.  This is especially apparrent in the care of pressure ulcers.  These skin problems are costing hospitals millions of dollars for care because of inaccurate documentation.  The need to educate the young nursing students about importance of documentation and accuracy is essential for the future.  I am actually surprised that the focus of nursing school was not completely on what costs the hospitals the most money but a complete caring, holistic approach.  I fear that in the future school will be focused on the more cost cutting, the better.

Siu Bong Wan

Module 2 Nur 701

Teaching Home Care Electronic Documentation Skills to Undergraduate Nursing Students

Kathleen M. Nokes, Judith Aponte, Donna M. Nickitas, Pamela Y. Mahon, Betsy Rodgers, Nancy Reyes, Joan Chaya, and Martin Dornbaum

Nursing Education Perspectives

NOKES, K. M., APONTE, J., NICKITAS, D. M., MAHON, P. Y., RODGERS, B., REYES, N., & ... DORNBAUM, M. (2012). Teaching Home Care Electronic Documentation Skills to Undergraduate Nursing Students. Nursing Education Perspectives, 33(2), 111-115. doi:10.5480/1536-5026-33.2.111

Why was this article, blog, post, or multimedia chosen?

             I chose this article because it interested me.  I went through my nursing curriculum without a class in EHR documentation.  Everything was examples of paper charts and school related template documentation.  This is not how EHR is represented in the real world.  EHRs vary so wildly and many are not standardized.  I wanted to see how effective electronic documentation classes could affect undergraduate nurses. 

What makes it interesting, appropriate, or reputable?

             I found it interesting because this is a new occurrence in the field of undergraduate nursing.  I did not have classes in computer documentation and home care especially.  This kind of field was not a focus for my school and I am curious as to why it was a class offered in this article.  This is a new occurrence and many undergraduate nurses I think could benefit from looking at EHRs in class, instead of orientation when hired.

Is it an opinion? Case study? Research study? Product review?

             This is a literature review of EHR content being taught in nursing schools and the home care settings.  The articles are searched and reviewed to analyze and formulate data for effectiveness.  The research was trying to understand what elements are needed for a competent education the the field of EHR and what is some basic templates in the home care setting of documentation.

What was the need, problem, issue or trend addressed in the article, blog, post, or multimedia?

            The trend being addressed is why are we teaching documentation skills to undergraduates?  This is an important article because it may lead to teaching documentation of EHRs in the classroom, not just for home care either.  These kinds of classes are becoming a trend because of the revolution of electronic charting.  This is being formally introduced in home care with mobile laptops and tablets.  The electronic documentation phenomenon allows less paperwork but more precise documentation of patient data, which is stored digitally.  

What was the solution for which technology had an answer?

            The solution was to introduce OASIS, a government funded reimbursement ready EHR system.  The students are to learn to use the standardized systems that are subsidized by the government and its beneficiaries.  The technology is for students to learn for future reference.  

What implications might this have in healthcare delivery?

             The healthcare system could learn a great deal from EHR introduction in the undergraduate program.  Programs that are standardized by the government for documentation are the most accurate for use in the real world.  This can prove useful because undergraduate students could have a reduced orientation to the computer system or it could help standardize a hospital wide government established EHR system.  The delivery of healthcare is already well into electronic documentation and students rarely see the EHR before being hired by a healthcare facility.  The trend of the curriculum should reflect how the healthcare field is changing and introduce elements that EHRs offer and what they can hope to expect when entering the healthcare world.  

What did you learn from it that might have application for your practice?

            I learned that the undergraduate populations of nursing students are still not introduced to electronic documentation.  This is the fault of a stagnant curriculum that does not reflect the processes of the real clinical world.  Electronic documentation is the new standard and students have to be introduced to the core components of documentation for home care or hospital care.  These kinds of classes could help students adjust to the EHR templates that are required for documentation.  This can affect my practice if I intend to go into a teaching position in undergraduate education.  I could introduce the core components of EHRs and what makes them similar versus different.  The government can facilitate change by standardizing much of the systems that are in use now so it could be easier to teach.  The EHRs currently vary so much and change so rapidly that students may become disenchanted because it may not be the system the students were introduced in school.  Technology advances so fast that hopes of a standard EHR system would prove beneficial for the education of the undergraduate classes.

NUR 701 WA 1 with Update

What I Learned

I learned that we are still long ways off from a standardized documentation method and language that could prove to be the de facto way to work.  It is boggling to know that so many different systems are available for purchase for the health facilities now.  Each one may offer a different sense of documentation and could prove harmful from all the different ways that are not suitable for medical facilities.  A standard method of documentation could be beneficial, but competition of companies should not be stifled.

Siu Bong Wan

Module 1 Nur 701

Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers

Dan Li, Denise Korniewicz

MEDSURG Nursing Issue Vol. 22Jan/Feb 2013 1 p17-25

Li, D., & Korniewicz, D. M. (2013). Determination of the Effectiveness of Electronic Health Records to Document Pressure Ulcers. MEDSURG Nursing, 22(1), 17-25.

Why was this article, blog, post, or multimedia chosen?

            This article was chosen because I was interested in the elements of the article.  There was research behind if Electronic Health Records (EHR) versus written documentation proved more useful in recording pressure ulcers on a medical surgical care unit.  I wanted to know if technology had improved documentation in this regard or worsened it.

What makes it interesting, appropriate, or reputable?

            The idea is interesting because there are so many different kinds of EHR out there for medical facilities to utilize.  Which one is best?  How does it affect documentation of pressure ulcers?   There are so many elements that create a competent EHR system and there is no real standardization of technology for facilities to utilize.  I found it appropriate to nursing informatics technology because it explores the use of EHR systems and how certain ones affect documentation of patient pressure ulcers.  The article appears reputable because it is published in the medsurg nursing journal. 

Is it an opinion? Case study? Research study? Product review?

            This research study analyzed a 560-bed hospital in Miami, Florida.  The pilot study utilized a descriptive study design to analyze the EHR versus the written medical record. 

What was the need, problem, issue or trend addressed in the article, blog, post, or multimedia?

            There was a problem in identifying correct documentation of pressure ulcers.  There were missing elements that were not reflective of routine hospital documentation practices of pressure ulcers.  This brings to the table standardization protocols for the EHR system and education for staff on how to document pressure ulcers according to policy.

What was the solution for which technology had an answer?

            Eleven patients developed pressure ulcers out of the 139 patients.  This documentation about the pressure ulcers were inconsistent, and not in accordance to hospital policy.  This in turn could increase costs to treat, and lengthen patient stays in the hospital.  The EHR compared to the written documentation varied significantly enough that EHR documentation is invalid in properly reporting pressure ulcers.

What implications might this have in health care delivery?

            The health care delivery system requires all pressure ulcers before and during admission to be documented, measured, and identified by trained clinicians.  This is only possible through sufficient education, knowledge, and expertise in the field.  The documentation must reflect the correct procedures and policies necessary to prevent significant pressure ulcer injuries.  If pressure ulcers are not correctly reflected in the documentation, the hospital is responsible for the costs of treatment and stay for that patient.  This is especially significant if infection, mortality, or morbidity were to increase. 

What did you learn from it that might have application for your practice?

            I have learned that proper documentation of pressure ulcers is imperative to cost consolidation and prevention of cost inflation.  There is incomplete documentation in my EHR as well and proper recording of healing is necessary to assess treatment.  Pressure ulcers are very serious patient quality elements that need to be addressed in the EHR interface.  This is especially important in photographs, dressing appearance, and frequency of recording.