EFFECTIVE INTEGRATION OF ELECTRONIC MEDICAL RECORD DOCUMENTATION IN NURSING ORIENTATION TO IMPROVE DOCUMENTATION COMPLIANCE
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Publisher:The Ohio State University
Series/Report no.:The Ohio State University. College of Nursing Doctor of Nursing Practice Final Document Projects
Since January 2015, healthcare organizations are required to report catheter device related infections which meet the National Health and Safety Network (NHSN) guidelines to regulatory bodies (Centers for Disease Control and Prevention [CDC], n.d.). The number of days Lines, Drains and Airways (LDA) catheters exist as active in the Electronic Medical Record (EMR) is also another quality indicator that is reported to other regulatory and accrediting bodies such as Nursing Database of Nursing Quality Indicators (NDNQI). In anticipation of the implementation of an infection control module within the EMR, a significant number of LDAs were still listed as active in the EMR, despite no additional documentation was on the LDA, nor were the patients where no longer still admitted as patients. The organization's current computer-based training focuses on how to use and navigate through the simulated EMR but the training does not incorporate EMR documentation at the time the of skill acquisition. The focus of interest for this project was implementation of an EMR simulated documentation exercise during nursing orientation. The accuracy of LDA documentation, perceived satisfaction and self-confidence of participants post simulation experience indicated the simulated documentation exercise was successful revealing 99% accuracy in documentation. The majority (95%) of the nurses were both satisfied and confident in the knowledge obtained from this simulation pilot project. By combining skills practice and concepts of electronic documentation into a logical order, nurse orientees observed, practiced related skills and documented the simulated experiences in a safe environment.
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