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Keywords:

  • checklist;
  • deficiencies electronic medical record;
  • bedside report

Poster Presentation

  1. Top of page
  2. Poster Presentation

Purpose for the Program

Innovative technology has resulted in the emergence of the electronic medical record (EMR) as the standard in healthcare documentation. Our labor and delivery (L&D) unit witnessed many positive changes since implementing an EMR. Patient information that may have a significant effect on our plan of care for a patient could have been omitted on the paper medical record. Healthcare professionals no longer struggle to interpret illegible entries. This improvement positively influences patient safety.

The program used in our L&D unit, Stork, is a product of Epic. Many nurses, accustomed to reviewing a paper chart to ensure that all expected components of that record were present and complete, have encountered some challenges. In Stork, nurses navigated the chart in many different directions. This approach allowed for important sections of the chart to be overlooked. Documentation deficiencies that could easily be spotted before the use of EMR were easily overlooked in the electronic system.

This EMR system made it challenging for the departing nurse to systematically inspect her documentation for flaws. Many hours were spent reviewing charts and discussing the challenges at unit meetings. Improvement was often fleeting, only to have the same defects arise again, which required more time educating and reminding staff via e-mails. Our nurses needed two things: (a) a list of required documentation and (b) a standardized order for gathering and recording the information.

Proposed Change

To implement a list of required documentation and a standardized order for gathering and recording the information.

Implementation, Outcomes, and Evaluation

A report checklist was created. Report in our unit is given at the bedside to include the patient and family during this exchange of information, allow correction of information, and reinforce the plan of care in the minds of all present. During report, both incoming and outgoing nurses review all components of the Stork chart listed on the checklist. The nurse handing over care, aware of deficits in the record, can correct incomplete documentation in real time.

Implications for Nursing Practice

The goal of this initiative is to standardize the order in which assessment data are reviewed during report and reveal opportunities to correct deficiencies. In addition, cost savings should occur as the hours spent reviewing charts, formulating action plans for improvement, and re-educating staff will be reduced. Daily reinforcement of the actions required by the registered nurse (RN) when caring for our patients (specifically monitoring and documenting a patient's temperature every 2 hours after rupture of membranes) will improve safety.