The Impacts of Clinical Documentation

Clinical documentation, specifically nursing documentation in electronic health records (EHRs), is a foundational component that captures the patients care from admission to discharge. The data and information included in nursing documentation provides detailed accounts regarding care such as assessments, complications, medications, resources used, education provided, orders, labs, and internal communications (article 1). The utilization of documentation in electronic health records (EHRs) for the purpose of enhancing nursing documentation has been a health priority over the last decade, with the primary focus to improve patient safety.

Though electronic health records (EHRs) have the initial intent of improving quality of care and displaying real time healthcare information, the issue of errors in nurse documentation and malfunctions within EHRs systems can heavily impact documentation compliance and patient safety efforts (article 1 and 2). The relevance of the impact of nursing and clinical documentation will further be discussed by analyzing the issue, identify how to improve HER documentation, provide an analysis utilizing quality models, a discussion of related factors, and application of tools to improve the issue.

Background and Scope of Problem

In 2011 the Center for Medicare and Medicaid services (CMS) began providing incentives to those providers/establishments that utilized Electronic Health records (article 9). It had been understood that paper documentation was prone to errors and time consuming for multiple sectors in healthcare teams (5). As Electronic Health Records (EHRs) became the standard of documentation, there was an overall improvement in documentation for particular items. Article 1 studies founds items such as immunization documentation increased by 50 % and emotional concerns increase by 145 % in performance once staff began utilizing electronic............... Continue