A Multifaceted Approach to Introduce Electronic Documentation

by Lee Williams, MSN, RN-BC

Lee Williams, MSN, RN-BC

By Lee Williams, MSN, RN-BC

HIMSS Clinical Informatics Insights

New information technologies are making an ever-increasing impact on today’s complex healthcare system. In fact, the federal government has mandated the use of electronic documentation in hospital settings in the Meaningful Use directive , which is supported by the Centers for Medicare and Medicaid Services. A recent study reported that nurses spend 19% of their time documenting patient care (Yee, et al., 2012).

Boston Children’s Hospital has taken a multifaceted approach to introduce the electronic documentation system to newly hired clinicians via a Learning Management System. The self-guided module is followed up with an in-class tutorial and testing session, and supplemented by the “just in time” orientation experience within the clinical setting.

Expert clinicians have created simulated documentation modules using snapshots of the electronic documentation system. These modules allow the learner to interact and document in a simulated patient chart. The in-class tutorial and testing session is individualized to the learners’ needs, depending on their work environment, and simulated scenarios represent situations clinicians can expect to encounter in their practice setting, including inpatient, outpatient, and specialty services. Each participant receives case studies to work through.

By logging on to a training domain that provides a replica of the production domain, they are able to optimize this simulation experience. Recognizing the complexity of our documentation system and the diversity of the patient population, we also rely on the clinician’s preceptor to provide real-time documentation learning opportunities and engage the new employee when particular skill opportunities present themselves.

Providing clinicians with this introduction to the documentation system prior to attending class, allows them to gain a certain level of comfort and familiarity with the system. The in-class session allows users to integrate their knowledge into actual documentation, and offers the facilitator an opportunity to highlight important features. Users have reported they feel comfortable with the documentation system, and have often expressed appreciation for this introduction before they begin practicing in the clinical area.

 

Reference

Yee, T., Needleman, J., Pearson, M., Parkerton, P., Parkerton, M., & Wolstein, J. (2012). The influence of integrated electronic medical records and computerized nursing notes on nurses’ time spent in documentation. Comput Inform Nurs, 30(6), 287-292. doi:10.1097/NXN.0b013e31824af835.

About the Contributor

Lee Williams is a Nursing Informatics Specialist at Boston Children’s Hospital. She has been in her current role for less than one year. Previously she had been in her education role for eight years, and holds her Masters in Nursing Education and her ANCC Certification in Professional Development. She is currently enrolled in a PhD program at Simmons College in Boston, with a focus in Health Professions Education.

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