Nursing Attitudes and Practices in Code Documentation Employing a New Electronic Health Record

Abstract

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.

Discrepancies between Retrospective Review of “Real-Time” Electronic Health Record Documentation and Prospective Observer Documentation of In-Hospital Cardiac Arrest Quality Metrics in an Academic Cardiac Intensive Care Unit

“…Our results build on a previous survey [14] of over 432 inpatient nurses, in which 23% of nurses reported participating in a code inaccurately documented in the EHRs using the same "real-time" code documentation module utilized in our institution. Our study's results offer quantitative evidence to substantiate those nurses' assertions.…”

“…We did not capture the experience of the documenting nurse who utilized the code reporting module. Experience has been shown to increase comfort with the code narrator module, with ICU nurses endorsing more comfort with the narrator module than medical ward nurses [14]. By virtue of working in the CICU, with the ICU in our hospital having the highest frequency of IHCA events, we can expect that our documenting nurses were more experienced than average nurses.…”

“…Our study's results offer quantitative evidence to substantiate those nurses' assertions. In addition, most of the nurse participants of the survey by Whalen et al [14] admitted to not using the module as intended, and instead retroactively documenting in the EHR module after the event. Nearly 43% of the nurses believed that retroactive EHR charting increased accuracy over real-time performance.…”

“…Technologies such as smartphone-or tablet-based applications [13] and electronic health record (EHR) modules [14] have been developed to facilitate real-time documentation to improve code documentation accuracy. In a study involving the simulation of IHCA, when compared to the gold standard of video records, tablet-based documentation had 88% sensitivity, while paper-based documentation only had 68% [13].…”

“…In a study involving the simulation of IHCA, when compared to the gold standard of video records, tablet-based documentation had 88% sensitivity, while paper-based documentation only had 68% [13]. Although documentation using EHRs seems promising, few authors have suggested that these solutions had the desired effect in improving code documentation accuracy, as most nurse participants still did not document the IHCA in real-time [14]. Thus, it remains uncertain whether the "real-time" documentation of IHCA events into the EHR at the time of IHCA events would accurately report IHCA quality metrics.…”