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.