The writer recalls the immergence of alternative methods of nursing documentation in the mid-to-late 1980s, which were designed to become more time effective methods of charting. Use of flow sheets, check sheets, and eventually computerized charting was the response to nurses’ long hours spent on documenting the events of the shift. Today, the use of technology to document patient data is at the forefront of health care discussions. Not only is the use of technology discussed as being more efficient in the delivery of healthcare, but also as a means of improving patient outcomes. As the use of technology explodes into the health care industry, its effects have the potential to become destructive elements to the nursing profession. This paper will discuss the evolution of nursing documentation, the immergence of health information technology, and the challenges it creates for the nursing profession.
Review of literature reveals much discussion on the concepts of health information and the technology used to manage this type of information i.e. health information technology. The U.S. Department of Health and Human Services (2009) describes health information technology as comprehensive management of medical information and the exchange of this information between health care consumers and providers. Given that the Healthcare Information and Management Systems Society (HIMSS) Nursing Informatics Awareness Task Force (2007) reports that an estimated 50% of a nurse’s time in spent on documentation, one could reason that nursing documentation is a very important process of nursing practice and an integral aspect of nursing intervention.
Evolution of Nursing Documentation
Historically, nursing documentation has been a hand- written account of the nurse’s fulfillment of the professional and legal duty of care. This documentation process has evolved to provide effective communication between health care professionals, a plan of patient care for the patient, an avenue for compensation from health care insurances, analysis of health care, a source for education and research, and the legal document of the patient’s medical position. Today, the nursing documentation process is undergoing revolutionary transformation. This is, in part, due to the vast amounts of medical-related knowledge generated. Kaminiski (2005) reports that information is doubling every five years, if not tripling. In addition, there is increasing pressure for healthcare systems to improve efficiency and effectiveness. The high rate of medical errors and rising healthcare costs are now the driving forces behind the transformation of information management, and affects not only nursing, but all healthcare professionals.
The United States healthcare system is moving assertively toward the widespread use of information technology (IT).Under the direction of President Bush, the position of National Coordinator for Health Information Technology was created with the goal of a nationwide adoption of electronic medical records within 10 years (Stein and Deese, 2004). In the 2008 election, both candidates called for implementation of electronic health records as a means of decreasing medical errors and curtailing healthcare costs. The Obama administration has recently requested additional budgeted funds of $19 billion for the purpose of health information technology development (Mosquere, 2009). In the president’s address to the nation recently, he reaffirmed his plans to promote electronic health records has a means to improve healthcare costs. It is apparent that under the present administration, electronic health records will become a reality.
Challenges for Nursing
Computer and telecommunication systems have proven to be effective management tools for health care data and communication of this information to other healthcare professionals and their use will become the way of the future. As the federal government plans for the United States to have electronic health records by 2014, the National League for Nurses (NLN) (2008) has found that the next generation of nurses will not be prepared to work in such a technology-rich environment. Hence, the NLN has made recommendations for the development of programs to help achieve competency in informatics.
The science of nursing informatics has evolved to aid in the management of nursing data. Kaminiski (2005) suggests that disciplines such as nursing, which are information intensive, require the careful investigation into the use of computers to process nursing information and nurses need to feel comfortable working with computerized data. Nursing leaders, such as the American Nurses Association (ANA) support skilled information management and in 1992, officially established the role of the informatics nurse specialist, offering the first credentialing exam in 1995 (HIMSS Nursing Informatics Awareness Task Force, 2007).
The HIMSS Nursing Informatics Task Force (2007) reports the revitalization and redefinition of the role of the nurse and nursing practice as an expected outcome of the IT initiatives. As the movement towards evidence-based practice drives the direction of health care, it is perceivable that it will become necessary for nurses to have key information for decision making at the point of care. Langowski (2005) defines point-of-care technology as a computerized patient record that includes all the patient data in one place and is accessible to caregivers at different locations. Langowski (2005) further explains that with this technology, software programs can be designed to assist health care providers in making decisions for individual patients, as data are entered for analysis by the computer software, and recommendations are made so decisions can be made quickly, with minimal errors. The HIMSS Nursing Informatics Awareness Task Force (2007) explains that when evidence-based practice is coded to an appropriate taxonomy system, the computerized nursing documentation will allow nurses to track their care and improve patient outcomes by implementing appropriate interventions for identified problems.
While electronic health records are designed to provide access to information compiled from various providers, regardless of their physical location or healthcare system, this network will provide access to healthcare information for clinical decision making nationwide. Thede (2008) reports that data stored electronically is increasingly available to identify patterns of health care provided and subsequent outcomes among large groups of people. Often, nursing care data does not go beyond what’s required of the employing institution or accrediting bodies. Thus, Thede (2008) explains that the electronic health record will contain no data about the decisions nurses make and data will not be used in healthcare planning. The nurse’s role in healthcare will remain indiscernible and not considered in healthcare policy.
Nursing documentation is a dynamic and complex process. As an educator of nursing students, the writer is concerned not only with the present gaps in nursing documentation to the electronic record, but with abilities of nursing students to learn the skill. Because institutions providing clinical experience to students utilize varying charting methods, students cannot become proficient at documentation. Just as Thede (2008) suggests that nurses decide what data is to be included in the electronic record and what terminology is used to record the data, educators must work to establish consistent documentation guidelines for students. This represents only a small challenge compared to the undertaking that the federal government has undertaken with regards to health information technology.
One can only surmise what future generations will say about what the healthcare industry is doing today. One would hope that future nurses would look back in awe at how nurses documented with paper and pen to present a complete picture of the patient’s condition. Or that they are grateful for the vision of nursing leaders to develop documentation guidelines that not only provides effective communication between health care professionals, a plan of patient care for the patient, an avenue for compensation from health care insurances, analysis of health care, a source for education and research, the legal document of the patient’s medical condition, but also has enabled the discipline of nursing to be instrumental in the development of health care policy.
Sadly, the writer fears that future generations will work in frustration as corporate institutions such as the local department stores develop and market digital health records systems, none of which communicate with each other, as the national goal has become. The writer also fears that without federal government intervention, a standardized documentation system will not be possible and with federal government intervention, individual autonomy will be compromised.
It seems apparent that the United States will adopt an electronic health recording system as a desperate solution to the rising cost of health care and with the hopes of improved quality of care. The immergence of change brings with it challenges that must be identified and planned for. The discipline of nursing must work as never before to remain an integral part of the health care industry. To become proficient with technology, recommendations from the NLN must be considered. Point-of-care technology must be carefully designed to reflect nursing’s role in healthcare. Educators must come together and work to develop consistent charting guidelines that reflect, good sound charting techniques as well as adaptability to the many electronic technologies that exist in the health care arena. This information technology cannot be allowed to become destructive elements to the nursing profession, but instead become avenues for its betterment.
Healthcare Information and Management Systems Society Nursing Informatics Awareness Task Force (2007). An emerging giant. Retrieved March 23, 2009 from: http://www.himiss.org
Kaminski, J. (2005). Nursing-informatices.com. Retrieved March 23, 2009 from: http://www.nursing-informatics.com
Langowski, C. (2005). The times they are a changing: effects of online nursing documentation systems. Quality Management in Health Care, 14(2), 121-125. Mosquera, M. (2009). IT, health care would get more under budget. FederalComputerWeek. Retrieved March 2, 2009 from:http://fcw.com/Articles/2009/02/2010-budget-health-care.aspx
National League for Nursing (2008). Position Statement. Preparing the next generation of nurses to practice in a technology-rich environment: an informatics agenda. Retrieved February, 2009 from:http://www.nln.org/aboutnln/PositionStatements/Informatics_052808
Stein, M. and Deese, D. (2004). Addressing the next decade of nursing challenges. Nursing Economics, 22(5), 273-279.
Thede, L. (2008). Informatics: the electronic health record: will nursing be on board when the ship leaves? Online Journal of Issues in Nursing, 13 (3). Retrieved February, 2009 from: www.cinahl.com/cgi-bin/refsvc?jid=1331&accno=2010054364
U.S. Department of Health and Human Services (2009). Health information technology. Retrieved march 23, 2009 from: http://www.hhs.gov/healthit/