A Topic Essay Paper on How Documentation is an Important Part of the Nursing Process

Research Topic Essay
Outlines
• Introduction.
• Definitions.
• Discussion.
1. My Interest.
2. Research Question.
• Conclusion
• References
• Topic articles

Introduction
This is a topic essay paper for research practicum course which discuss about documentation. Documentation is an important part of the nursing process; it is a careful and accurate record keeping. It protects the client’s welfare; clients mean individual, families, groups, population who need nursing expertise. By documentation the nurse can communicate with other health professionals. It is needed to meet legal and professional standards.
The nursing documentation should include:
• Description of the assessment and care plan that is given to the client.
• The important information that is expressed by your client and your response to their needs.
• Any management that you provided to the client for the continuity of care.
• The understanding and fulfillment of your duty of care.

The documentation tools are different from one hospital to another, but they are having some basic ones. The common tolls that you might see are:
• Nursing assessment sheet.
• Nursing care plan.
• Vital signs.
• Fluid balance chart.
• Medicine/drug chart.
• Informed consent.
• Incident/accident report.

The topic that I choose is the effect of computerized documentation on the patient quality of care and compares it with effect of the written documentation.

Definitions
Documentation is “any written or electronically made information about client that give details about the care or service provided to the client”.
The definition of computerized documentation or electronic health records is “is longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunization, laboratory data, and radiology reports. It has the ability to generate a complete record of clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface-including evidence-based decision support quality management, and outcomes reporting.” or “a client’s electronic record is a collection of the personal health information of a single individual, entered or accepted by health care provider, and stored electronically, under strict security.”

Many researches define the quality of care as:
• Doing the right thing ( only when needed)
• In the right way ( use appropriate test or procedure)
• To achieve the best possible results
It also means to do these things in right balance of services by:
• Avoiding under use ( not taking vital signs for the patient, or not documenting some small things that happened to the patient or care given to the patient and considering them as unnecessary things)
• Avoiding overuse ( doing test for patient that doesn’t need, in documentation by documenting stories in details)
• Eliminating misuse ( giving medication that have dangerous interaction, in documentation writing things that didn’t happen with the patient which my effect the patient’s safety jut to avoid facing any problem)

Electronic health records (EHR) or computerized documentations are a new technology that includes all the information that is stored by health care professionals who deal with the clients previously. It is a technology that keeps the information secured and private, at the same time it is available 24 hours 7 days a week for the health care professionals in the hospital itself or in the all community. It supports the vision guiding the plan:”the right information in the right hands at the right time to support personal health, health care decision-making and health system sustainability”.
To improve the patient quality of care we need to reduce the errors in documentation, by providing safer care to the patient, dealing with the patient for longer time to provide more care, and keep the patient health records safe and secure. There are more things we have to provide for the patient to improve the best quality of care, the most important things that we should practice the updated evidence-based practices on our documentation.

Discussion:
My Interest
The interest that I would like to study is to differentiate between the effect of the computerized documentation (or electronic health records) and written documentation (or manual documentation) on the client’s (or patient’s) quality of care. I derived this topic from the articles that I have read and from the community that I have experience on (Abu Dhabi, Mafraq Hospital). Most of the articles used the EHR to study the staff compliance to some evidence-based practices, to core measures, or nursing process (Electronic Nursing Documentation in Primary Health Care article, use of Computerized ICU Documentation to Capture ICU Core Measures article), some of them are studying the nurse’s attitudes toward the EHR (Electronic Health Records Documentation in Nursing article), other evaluated the effect of the EHR on the nursing documentation practices ( A Randomized Evaluation of a Computer-Based Nursing Documentation System article) , and I didn’t find any articles that studied about EHR and the patient quality of care. I choose this topic to study the implementation of the electronic health records and how it improves the patient quality of care. In my community most of the nursing staff has no idea about the basics of the computer so they might face problems while dealing with the computer systems which this might affect the documentation process which is used for the patient safety, but before telling these things we have to do so many studies before implementing the EHR system and after implementing it. Then we have to compare these two and see if the EHR can improve the patient quality of care or not. In my opinion I think EHR might improve the client’s quality of care because it will take less time in documentation, it is available at any time, and there will be less chances to lose any patient information. I have to take in consideration that most of the staff is not having any idea about computer system, so to study this topic we have to educate the stuff about the computer and how to deal with it.

Research Question
To study if the electronic documentation provide enhanced quality of care more than the written nursing documentation.
• Does the electronic nursing documentation provide enhanced quality of patient care more than the written nursing documentation?

Conclusion
Documentation is an important process in nursing that should be taken in consideration. It is important to study any implementation in nursing documentation and the effect of this implementation on the nursing documentation process which is used for patient’s safety. Implementing computerized documentation and its effect on the quality of care that is provided for the clients will need to be studied. If this system will not provide any improve in care, why we have to use this technology. I know there will be some good things from using computerized systems for example it is not coasting a lot there will be no papers to be used, no manual files which will need a big space in the hospital to keep it in, and it is more secured and safe than the written documentation, but we should be sure that there will be an improve in the quality of care or at least the quality of care will remain same to the one with the written documentation. The quality of care has many concepts, to decide the concepts of the care quality I have to review the literature to know what are the quality concepts to study on and suitable the community that I want to make my study on.

References
• Registered Nurses Association of British Columbia, Nursing Documentation. (2003). Nursing Documentation. www.mabc.bc.ca
• Rockville, MD. (2005).Agency for Healthcare Research and Quality Guide to Health Care Quality How to know it when you see it. www.ahrq.gov
• Center for Enterprise Modernization. (2006). Electronic Health Records Overview.
Five Articles chosen for the topic:
• Linda E. Moody, PhD, MPH, FAAN, Elaine Slocumb, PhD, RN, Bruce Berg, MD, Donna Jackson, MSN, RN, BC. (2004). Electronic Health Records Documentation in Nursing: Nurse’s Perception, Attitudes, and Preferences. Vol. 22. 337-334
• E. Ammenwerth, R. Eichstadter, R. Haux, U. Pohl, S. Rebel. S. Ziegler. (2001). A Randomized Evaluation of a Computer-Based Nursing Documentation System. Method Inform Med; 40: 61-8
• Wendy Lynn Wahl, MD, AkkeNeel Talsma, RN, PhD, Carrie Dawson, RN, MS, Sharon Dickinson, RN, MSN, Kori Pennington, RN, NP, Donna Wilson, RN, Saman Arbabi, MD, MPH, and Paul A. Taheri, MD, MBA, Ann Arbor, Mich. (2006). Use of computerized ICU documentation to capture ICU core measures. J.surg. Vol .140.684-690
• Eva Tornvall, RN, (PhD student), Susan Wilhelmsson, PhD, RN, R&Q (Administrator) and Lis Karin Wahren, (Associate Professor). (2004). Electronic nursing documentation in primary health care. Scand J Caring Sci; 18; 310-317
• Julie Considine, RN, RM, BN, EmergCret, MN(Research), FRCNA, Robyn Potter, RN, ICUCert, Jane Jenkins, RN, EmergCert, BHSci (Nsg). (2006). Australian Emergency Nursing Journal. Can written nursing practice standards improve documentation of initial assessment of ED patients?. 9,11-18