2.50
Hdl Handle:
http://hdl.handle.net/10755/344152
Category:
Abstract
Type:
Poster
Title:
Call 911: Our Documentation Died!
Author(s):
Kreger, Stacy; Heckler, Debbie; Gonder, Claire; Szymanski, Lauren; Godwin, Erin; Cimino, Nancy; Profili, Angela
Lead Author STTI Affiliation:
Non-member
Author Details:
Stacy Kreger, RN, stacykreger@yahoo.com; Debbie Heckler, RN; Claire Gonder, RN; Lauren Szumanski, RN; Erin Godwin, RN; Nancy Cimino, RN; Angela Profili, RN
Abstract:
POSTER AWARD WINNER - Evidence-based Practice Abstract Purpose: Our Emergency Department converted to an EMR (electronic medical record) in February 2013. Despite in-services, many nurses were uncomfortable with how and where to document their care. In April 2013, four bedside nurses and three leadership nurses formed ENBEE (Emergency Nurses Building Emergency Excellence), a quality improvement initiative, to create uniform documentation guidelines. Design: Random evaluations revealed deficient documentation, which impacts department goals of patient safety, continuity of care, reimbursement criteria, and liability protection. This vulnerability resulted in the need for a quality improvement project. Setting: The project setting is an urban emergency department certified level II trauma center with 51 beds and 60,000 annual visits. Participants/Subjects: Seventy Emergency department nurses comprised of 87% females and 13% males. Half of the nurses have less than two years of nursing experience. Methods: A brief literature search including Pub Med, ENA (Emergency Nurses Association) scope and standards of practice, hospital policies and procedures did not outline what should be documented. ENBEE developed documentation guidelines based on The Joint Commission standards, departmental policy and collective practice founded on the nursing process. Guidelines highlighted nine areas for improvement including: vital signs, focused reassessments, intake and output, cardiac monitoring, pain assessments, purposeful rounding, discharge criteria, technician documentation and psychiatric care. Each area defines the minimal expected documentation frequency as well as how and where to document in the EMR. A template for chart reviews includes all nine areas plus fall risk and skin integrity assessments. The guidelines and chart review process were disseminated through detailed emails, in-services, staff meetings, orientation, and job aids. All staff members were assigned to an ENBEE representative responsible for chart reviews and providing individual feedback. Results/Outcomes: A random, convenience sample of 206 chart reviews highlighted 22 variables for completeness, both pre and post guideline introduction. Although the small sample size resulted in no statistical significance, improvements were noted in 19 variables. Comparisons were made between February and October 2013. The most improved variable was hourly rounding with compliance of 30% to 83% (8.8% change /month). Improved variables include: focused reassessments 20% to 64% (7.3% change/month), cardiac monitoring 6% to 44% (6.3% change/month), fall risk assessment 61% to 96% (5.8% change/month), vital sign 41% to 65% (4% change/ month), initial pain assessment 78% to 100% (3.7% change/ month), skin integrity 77% to 92% (2.5% change/ month), psychiatric patient nutrition 0% to 50% (8.3% change/ month). The remaining measures showed some improvement with the exception of two, pain education on discharge and suicide assessment every shift, that had very small sample sizes. Implications: Direct staff evaluations have slowly increased charting awareness and compliance towards department goals. Most staff welcomed the documentation guidelines and monthly feedback. Limitations of our project include reviewer variability, diverse styles of feedback, chart review time, resistance from some staff members, and high staff attrition. Quality emergency nursing documentation during transition to an EMR needs resuscitation! Clear expectations and direct staff feedback are the catalysts to recovery.
Keywords:
EMR Documentation; Deficient Documentation; Uniform Documentation Guidelines
Repository Posting Date:
4-Feb-2015
Date of Publication:
4-Feb-2015
Conference Date:
2014
Conference Name:
2014 ENA Annual Conference
Conference Host:
Emergency Nurses Association
Conference Location:
Indianapolis, Indiana, U.S.A.
Description:
2014 ENA Annual Conference Theme: Safe Practice, Safe Care. Held at the Indiana Convention Center
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.language.isoen_USen_GB
dc.type.categoryAbstracten_GB
dc.typePosteren_GB
dc.titleCall 911: Our Documentation Died!en_GB
dc.contributor.authorKreger, Stacyen_GB
dc.contributor.authorHeckler, Debbieen_GB
dc.contributor.authorGonder, Claireen_GB
dc.contributor.authorSzymanski, Laurenen_GB
dc.contributor.authorGodwin, Erinen_GB
dc.contributor.authorCimino, Nancyen_GB
dc.contributor.authorProfili, Angelaen_GB
dc.contributor.departmentNon-memberen_GB
dc.author.detailsStacy Kreger, RN, stacykreger@yahoo.com; Debbie Heckler, RN; Claire Gonder, RN; Lauren Szumanski, RN; Erin Godwin, RN; Nancy Cimino, RN; Angela Profili, RNen_GB
dc.identifier.urihttp://hdl.handle.net/10755/344152-
dc.description.abstractPOSTER AWARD WINNER - Evidence-based Practice Abstract Purpose: Our Emergency Department converted to an EMR (electronic medical record) in February 2013. Despite in-services, many nurses were uncomfortable with how and where to document their care. In April 2013, four bedside nurses and three leadership nurses formed ENBEE (Emergency Nurses Building Emergency Excellence), a quality improvement initiative, to create uniform documentation guidelines. Design: Random evaluations revealed deficient documentation, which impacts department goals of patient safety, continuity of care, reimbursement criteria, and liability protection. This vulnerability resulted in the need for a quality improvement project. Setting: The project setting is an urban emergency department certified level II trauma center with 51 beds and 60,000 annual visits. Participants/Subjects: Seventy Emergency department nurses comprised of 87% females and 13% males. Half of the nurses have less than two years of nursing experience. Methods: A brief literature search including Pub Med, ENA (Emergency Nurses Association) scope and standards of practice, hospital policies and procedures did not outline what should be documented. ENBEE developed documentation guidelines based on The Joint Commission standards, departmental policy and collective practice founded on the nursing process. Guidelines highlighted nine areas for improvement including: vital signs, focused reassessments, intake and output, cardiac monitoring, pain assessments, purposeful rounding, discharge criteria, technician documentation and psychiatric care. Each area defines the minimal expected documentation frequency as well as how and where to document in the EMR. A template for chart reviews includes all nine areas plus fall risk and skin integrity assessments. The guidelines and chart review process were disseminated through detailed emails, in-services, staff meetings, orientation, and job aids. All staff members were assigned to an ENBEE representative responsible for chart reviews and providing individual feedback. Results/Outcomes: A random, convenience sample of 206 chart reviews highlighted 22 variables for completeness, both pre and post guideline introduction. Although the small sample size resulted in no statistical significance, improvements were noted in 19 variables. Comparisons were made between February and October 2013. The most improved variable was hourly rounding with compliance of 30% to 83% (8.8% change /month). Improved variables include: focused reassessments 20% to 64% (7.3% change/month), cardiac monitoring 6% to 44% (6.3% change/month), fall risk assessment 61% to 96% (5.8% change/month), vital sign 41% to 65% (4% change/ month), initial pain assessment 78% to 100% (3.7% change/ month), skin integrity 77% to 92% (2.5% change/ month), psychiatric patient nutrition 0% to 50% (8.3% change/ month). The remaining measures showed some improvement with the exception of two, pain education on discharge and suicide assessment every shift, that had very small sample sizes. Implications: Direct staff evaluations have slowly increased charting awareness and compliance towards department goals. Most staff welcomed the documentation guidelines and monthly feedback. Limitations of our project include reviewer variability, diverse styles of feedback, chart review time, resistance from some staff members, and high staff attrition. Quality emergency nursing documentation during transition to an EMR needs resuscitation! Clear expectations and direct staff feedback are the catalysts to recovery.en_GB
dc.subjectEMR Documentationen_GB
dc.subjectDeficient Documentationen_GB
dc.subjectUniform Documentation Guidelinesen_GB
dc.date.available2015-02-04T11:27:26Z-
dc.date.issued2015-02-04-
dc.date.accessioned2015-02-04T11:27:26Z-
dc.conference.date2014en_GB
dc.conference.name2014 ENA Annual Conferenceen_GB
dc.conference.hostEmergency Nurses Associationen_GB
dc.conference.locationIndianapolis, Indiana, U.S.A.en_GB
dc.description2014 ENA Annual Conference Theme: Safe Practice, Safe Care. Held at the Indiana Convention Centeren_GB
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.en_GB
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