Completion of electronic nursing documentation of inpatient admission assessment: Insights from Australian metropolitan hospitals

Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program

BACKGROUND

Introducing an electronic medical record (EMR) system into a complex health care environment fundamentally changes clinical workflows and documentation processes and, hence, has implications for patient safety. After a multisite "big-bang" EMR implementation across our large public health care organization, a quality improvement program was developed and implemented to monitor clinician adoption, documentation quality, and compliance with workflows to support high-quality patient care.

OBJECTIVE

Our objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation.

METHODS

The Model for Improvement quality improvement framework guided cycles of "Plan, Do, Study, Act." Steps included design, pre- and pilot testing of an audit tool to reflect expected practices for EMR documentation that examined quality and completeness of documentation 1-year post-EMR implementation. Analysis of initial audit results was then performed to (1) provide a baseline to benchmark comparison of ongoing improvement and (2) develop targeted intervention activities to address identified gaps.

RESULTS

Analysis of 1,349 EMR record audits as a baseline for the first cycle of EMR quality improvement revealed five out of nine nursing and midwifery documentation components, and four out of ten medical documentation components' completion and quality were classified as good (>80%). Outputs from this work also included a framework for strategies to improve EMR documentation quality, as well as an EMR data dashboard to monitor compliance.

CONCLUSION

This work provides the foundation for the development of quality monitoring frameworks to inform both clinician and EMR optimization interventions using audits and feedback. Discipline-specific differences in performance can inform targeted interventions to maximize the effective use of resources and support longitudinal monitoring of EMR documentation and workflows. Future work will include repeat EMR auditing.

Adopting an American framework to optimize nursing admission documentation in an Australian health organization

Objective

Apply and modify the American Essential Clinical Dataset (ECD) approach to optimize the data elements of an electronic nursing admission assessment form in a metropolitan Australian local health district.

Materials and Methods

We used the American ECD approach but made modifications. Our approach included (1) a review of data, (2) a review of current admission practice via consultations with nurses, (3) a review of evidence and policies, (4) workshops with nursing and informatics teams in partnership with the electronic medical record (eMR) vendor, and (5) team debrief sessions to consolidate findings and decide what data elements should be kept, moved, or removed from the admission form.

Results

Of 165 data elements in the form, 32% (n = 53) had 0% usage, while 25% (n = 43) had 100% usage. Nurses’ perceptions of the form’s purpose varied. Eight policy documents specifically prescribed data to be noted at admission. Workshops revealed risks of moving or removing data elements, but also uncovered ways of streamlining the form. Consolidation of findings from all phases resulted in a recommendation to reduce 91% of data elements.

Discussion

Application of a modified ECD approach allowed the team to identify opportunities for significantly reducing and reorganizing data elements in the eMR to enhance the utility, quality, visibility, and value of nursing admission data.

Conclusion

We found the modified ECD approach effective for identifying data elements and work processes that were unnecessary and duplicated. Our findings and methodology can inform improvements in nursing clinical practice, information management, and governance in a digital health age.