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Nursing Attitudes and Practices in Code Documentation Employing a New Electronic Health RecordFunding None.
Objective Based on feedback from nurses regarding the challenges of code documentation following the implementation of a new electronic health record (EHR), we sought to better understand inpatient nurse attitudes and practices in code documentation and to identify opportunities for improvement.
Methods An anonymous electronic survey was distributed to all inpatient nurses working at a single, 999-bed, university-based, and quaternary care hospital. Participation in the study was voluntary and consent was implied by survey completion.
Results Overall, 432 (14%) of 3,121 inpatient nurses completed the survey. While nearly 80% of respondents indicated feeling very comfortable using computers for personal use, only 5% felt very comfortable navigating the EHR to document codes in real time. While 53% had documented codes in the new EHR, most admitted to documenting on paper with retroactive entry into the EHR. About 25% reported having participated in a code that was not accurately documented in the new EHR. All respondents provided specific suggestions for improving the EHR interface, and over 90% expressed interest in having opportunities to practice code documentation using simulated code events.
Conclusion Despite completion of training modules in code documentation in a new EHR, many inpatient nurses in a single institution feel uncomfortable documenting codes directly into the EHR, and some question the accuracy of this documentation. Improving EHR functionality based on specific recommendations from end-users coupled with more practice documenting simulated codes may ease EHR navigation, leading to nurses' acceptance of the EHR tool, more accurate and efficient documentation, greater nurse satisfaction and more appropriate quality improvement measures.
Keywordssimulation and modeling - electronic health records and systems - nurse - data quality - user acceptance and resistance - workarounds - critical care and emergency
Protection of Human and Animal Subjects
Institutional review board approval was obtained.
Received: 30 November 2020
Accepted: 16 May 2021
Article published online:
23 June 2021
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- 1 Taber's Cyclopedic Medical Dictionary. 18th edition.. Copyright 1997 Philadelphia, PA: FA Davis Company; 312
- 2 Kittinger BJ, Matejicka II A, Mahabir RC. Surgical precision in clinical documentation connects patient safety, quality of care, and reimbursement. Perspect Health Inf Manag 2016; 13: 1f
- 3 Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK. American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR) Investigators. Hospital variation in time to defibrillation after in-hospital cardiac arrest. Arch Intern Med 2009; 169 (14) 1265-1273
- 4 Painter LM, Dudjak LA, Kidwell KM, Simmons RL, Kidwell RP. The nurse's role in the causation of compensable injury. J Nurs Care Qual 2011; 26 (04) 311-319
- 5 Lyons III JM, Martinez JA, O'Leary JP. Medical malpractice matters: medical record M & Ms. J Surg Educ 2009; 66 (02) 113-117
- 6 JCAHO hospital accreditation standards. Accessed November 9, 2020 at: https://www.jointcommission.org/facts_about_joint_commission_accreditation_standard
- 7 Resuscitation Central Hospital Code Documentation. Accessed November 9, 2020 at: https://www.resuscitationcentral.com/documentation/joint-commision-and-resuscitation
- 8 Sittig DF, Singh H. Electronic health records and national patient-safety goals. N Engl J Med 2012; 367 (19) 1854-1860
- 9 Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med 2009; 360 (15) 1477-1479
- 10 Blumenthal D. Launching HITECH. N Engl J Med 2010; 362 (05) 382-385
- 11 Carayon P, Cartmill R, Blosky MA. et al. ICU nurses' acceptance of electronic health records. J Am Med Inform Assoc 2011; 18 (06) 812-819
- 12 Laramee AS, Bosek M, Shaner-McRae H, Powers-Phaneuf T. A comparison of nurse attitudes before implementation and 6 and 18 months after implementation of an electronic health record. Comput Inform Nurs 2012; 30 (10) 521-530
- 13 Yen PY, McAlearney AS, Sieck CJ, Hefner JL, Huerta TR. Health information technology (HIT) adaptation: refocusing on the journey to successful HIT implementation. JMIR Med Inform 2017; 5 (03) e28
- 14 Despont-Gros C, Mueller H, Lovis C. Evaluating user interactions with clinical information systems: a model based on human-computer interaction models. J Biomed Inform 2005; 38 (03) 244-255
- 15 Sapyta YY, Eiger C. Improving pediatric nurses' knowledge, accuracy, and confidence through code documentation simulation. Clin Simul Nurs 2017; 13 (06) 278-283
- 16 Grigg E, Palmer A, Grigg J. et al. Randomised trial comparing the recording ability of a novel, electronic emergency documentation system with the AHA paper cardiac arrest record. Emerg Med J 2014; 31 (10) 833-839
- 17 Ibrahim S, Donelle L, Regan S, Sidani S. Predicting registered nurses' behavioural intention to use electronic documentation system in home care: application of an adapted unified theory of acceptance and use of technology model. Nurs Leadersh (Tor Ont) 2019; 32 (02) 48-70
- 18 Song L, Park B, Oh KM. Analysis of the technology acceptance model in examining hospital nurses' behavioral intentions toward the use of bar code medication administration. Comput Inform Nurs 2015; 33 (04) 157-165
- 19 Tubaishat A. Perceived usefulness and perceived ease of use of electronic health records among nurses: application of technology acceptance model. Inform Health Soc Care 2018; 43 (04) 379-389
- 20 Su L, Waller M, Kaplan S, Watson A, Jones M, Wessel DL. Cardiac resuscitation events: one eyewitness is not enough. Pediatr Crit Care Med 2015; 16 (04) 335-342
- 21 Zadvinskis IM, Garvey Smith J, Yen PY. Nurses' experience with health information technology: longitudinal qualitative study. JMIR Med Inform 2018; 6 (02) e38
- 22 Peace JM, Yuen TC, Borak MH, Edelson DP. Tablet-based cardiac arrest documentation: a pilot study. Resuscitation 2014; 85 (02) 266-269
- 23 The Joint Commission Technical Advisory Panel to Identify or Maintain Performance Measures for Sudden Cardiac Arrest (US). Accessed 2013 at: http://www.jointcommission.org/sudden_cardiac_arrest_initiatives/
- 24 Grundgeiger T, Albert M, Reinhardt D, Happel O, Steinisch A, Wurmb T. Real-time tablet-based resuscitation documentation by the team leader: evaluating documentation quality and clinical performance. Scand J Trauma Resusc Emerg Med 2016; 24: 51
- 25 Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. 2nd edition. 2015. Saddle River, NJ: Pearson Education Inc;
- 26 Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27 (01) 10-28
- 27 Yager PH, Lok J, Klig JE. Advances in simulation for pediatric critical care and emergency medicine. Curr Opin Pediatr 2011; 23 (03) 293-297
- 28 Weinstock PH, Kappus LJ, Garden A, Burns JP. Simulation at the point of care: reduced-cost, in situ training via a mobile cart. Pediatr Crit Care Med 2009; 10 (02) 176-181
- 29 Hackl WO, Rauchegger F, Ammenwerth E. A nursing intelligence system to support secondary use of nursing routine data. Appl Clin Inform 2015; 6 (02) 418-428
- 30 Verma M, Gupta S. Problems faced by nurses in use of electronic health records during clinical practice. Stud Health Technol Inform 2016; 225: 985-986
- 31 Takian A, Sheikh A, Barber N. We are bitter, but we are better off: case study of the implementation of an electronic health record system into a mental health hospital in England. BMC Health Serv Res 2012; 12: 484
- 32 Carrington JM, Effken JA. Strengths and limitations of the electronic health record for documenting clinical events. Comput Inform Nurs 2011; 29 (06) 360-367
- 33 Kutney-Lee A, Brooks Carthon M, Sloane DM, Bowles KH, McHugh MD, Aiken LH. Electronic health record usability: associations with nurse and patient outcomes in hospitals. Med Care 2021; DOI: 10.1097/MLR.0000000000001536.