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Staff members on a medicalsurgical unit at a large community hospital developed and implemented a unit-specific standardized documentation project. Methods, outcomes, limitations, and recommendations regarding the success of the project are discussed.
Documentation of patient care is based on requirements of accreditation bodies and federal and state regulations (Centers for Medicare & Medicaid Services, 2015; The Joint Commission, 2015). A patient's electronic health record (EHR) has multiple uses, including communication between healthcare providers and staff, evaluation of care, and protection of legal interests of the patient, hospital, and provider.
The project site adopted the EHR EPIC (Epic Systems Corporation; Verona, WI) in September 2012, and the system was standardized for the facility based on hospital needs and policies. EPIC had multiple paths for charting the same information, and nurses sometimes documented differently. With data located in multiple areas of the EHR, audits and data collection for accreditation and federal requirements became difficult. In addition, the ability to acquire and transfer accurate information was essential to achieving goals for meaningful use of EHRs. The need to standardize patient documentation was identified on the project unit.
Charting by exception was the training standard when the EHR was instituted at the hospital (Kerr, 2013). Documentation is completed as within defined limits (WDL) or exception (X). For an assessment of WDL, identified findings must be present. If all criteria are met, WDL could be charted with no further data needed. X is charted when at least one of the criteria is not met for the system. The data for the exception are described in the assessment. This method of documentation leads to the assumption the data not documented are WDL.
Project Site and Reasons for Change
Four North is a 30-bed medicalsurgical unit that provides care for patients age 18 and older. A unitspecific project was initiated to standardize documentation to make it easier to identify and evaluate specific patient information and assessments in the EHR.
Baseline data were obtained before staff education on the new documentation standards. Thirty patient medical records were chosen randomly from patient admissions in April-June 2014. They were reviewed using the author-developed Unit Chart Audit Sheet; documentation for individual registered nurses (RNs) and certified nursing assistants (CNAs) was not included. Inter-rater reliability of...