Electronic Health Record Template Customization and the Impact on Nursing Satisfaction and Documentation Compliance

2.50
Hdl Handle:
http://hdl.handle.net/10755/622726
Category:
Full-text
Format:
Text-based Document
Type:
DNP Capstone Project
Level of Evidence:
N/A
Research Approach:
Translational Research/Evidence-based Practice
Title:
Electronic Health Record Template Customization and the Impact on Nursing Satisfaction and Documentation Compliance
Author(s):
Engstrom, Autumn
Advisors:
Hoopingarner, Diana Shaw; D'Antonio, Jocelyn; Couch, Kimberly A.
Degree:
DNP
Degree Year:
2017
Grantor:
Capella University
Abstract:

Documentation is a crucial component of safe and effective patient care.  A priority for health care organizations is to ensure their electronic health record (EHR) systems are used safely and effectively.  They should be clinically operational, user-friendly, and suit the needs of the end user (HealthIT.gov, 2017).  If EHR templates do not exist, are not customized to the needs of the user, or are not user-friendly, risks of failing to maintain proper documentation exist (Mosher, Lose, Leslie, Pennathur, & Kaboli, 2015).  The purpose of this project was to develop and implement an EHR template for obstetrical and postpartum nurses to document postpartum hemorrhages (PPH) that progress to Stages 2 and 3.  A customized template did not exist in the EHR to document this type of event.  The template was created using information from the California Maternal Quality Care Collaborative (CMQCC, 2015) obstetric hemorrhage emergency management plan checklists.  These checklists are evidence-based guidelines and are included in a policy at the project site.  Everett Rogers’s diffusion of innovations theory served as the theoretical framework to guide the change.  Data were collected from a researcher-designed survey and chart reviews.  A convenience sample of nurses (N = 30) participated, and eight completed the survey.  After template implementation, eighteen Stage 2 and 3 PPHs occurred, and the template was used twice.  The template compliance rate was 11%.  The project yielded several significant findings.  Though not expected, a decrease occurred in the mean quantitative blood loss for Stage 2 and 3 PPHs post-template implementation.  Results suggested that the creation of a customized EHR template had a favorable effect on nursing satisfaction and documentation compliance of an evidence-based obstetric hemorrhage care guideline.  Substantial benefits can result when EHR technology is used to its fullest extent.

Keywords:
Electronic health record (EHR); postpartum hemorrhage; Templates; customization
CINAHL Headings:
Electronic Health Records; Nurse Attitudes; Organizational Compliance; Postpartum Hemorrhage; Obstetric Nursing
Note:
This work has been approved through a faculty review process prior to its posting in the Virginia Henderson Global Nursing e-Repository.
Repository Posting Date:
2017-09-22T14:48:33Z
Date of Publication:
2017-09-22

Full metadata record

DC FieldValue Language
dc.contributor.advisorHoopingarner, Diana Shawen
dc.contributor.advisorD'Antonio, Jocelynen
dc.contributor.advisorCouch, Kimberly A.en
dc.contributor.authorEngstrom, Autumnen
dc.date.accessioned2017-09-22T14:48:33Z-
dc.date.available2017-09-22T14:48:33Z-
dc.date.issued2017-09-22-
dc.identifier.urihttp://hdl.handle.net/10755/622726-
dc.description.abstract<p class="APA">Documentation is a crucial component of safe and effective patient care.  A priority for health care organizations is to ensure their electronic health record (EHR) systems are used safely and effectively.  They should be clinically operational, user-friendly, and suit the needs of the end user (HealthIT.gov, 2017).  If EHR templates do not exist, are not customized to the needs of the user, or are not user-friendly, risks of failing to maintain proper documentation exist (Mosher, Lose, Leslie, Pennathur, & Kaboli, 2015).  The purpose of this project was to develop and implement an EHR template for obstetrical and postpartum nurses to document postpartum hemorrhages (PPH) that progress to Stages 2 and 3.  A customized template did not exist in the EHR to document this type of event.  The template was created using information from the California Maternal Quality Care Collaborative (CMQCC, 2015) obstetric hemorrhage emergency management plan checklists.  These checklists are evidence-based guidelines and are included in a policy at the project site.  Everett Rogers’s diffusion of innovations theory served as the theoretical framework to guide the change.  Data were collected from a researcher-designed survey and chart reviews.  A convenience sample of nurses (<em>N </em>= 30) participated, and eight completed the survey.  After template implementation, eighteen Stage 2 and 3 PPHs occurred, and the template was used twice.  The template compliance rate was 11%.  The project yielded several significant findings.  Though not expected, a decrease occurred in the mean quantitative blood loss for Stage 2 and 3 PPHs post-template implementation.  Results suggested that the creation of a customized EHR template had a favorable effect on nursing satisfaction and documentation compliance of an evidence-based obstetric hemorrhage care guideline.  Substantial benefits can result when EHR technology is used to its fullest extent.</p>en
dc.formatText-based Documenten
dc.language.isoen_USen
dc.rights.urihttp://creativecommons.org/licenses/by-nc-nd/4.0/*
dc.subjectElectronic health record (EHR)en
dc.subjectpostpartum hemorrhageen
dc.subjectTemplatesen
dc.subjectcustomizationen
dc.titleElectronic Health Record Template Customization and the Impact on Nursing Satisfaction and Documentation Complianceen_US
dc.typeDNP Capstone Projecten
thesis.degree.grantorCapella Universityen
thesis.degree.levelDNPen
dc.description.noteThis work has been approved through a faculty review process prior to its posting in the Virginia Henderson Global Nursing e-Repository.-
thesis.degree.year2017en
dc.type.categoryFull-texten
dc.evidence.levelN/Aen
dc.research.approachTranslational Research/Evidence-based Practiceen
dc.subject.cinahlElectronic Health Recordsen
dc.subject.cinahlNurse Attitudesen
dc.subject.cinahlOrganizational Complianceen
dc.subject.cinahlPostpartum Hemorrhageen
dc.subject.cinahlObstetric Nursingen
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