Essay On Nursing Documentation

Nursing documentation is an important factor of healthcare delivery today. The use of information and communication technology offers opportunities for improving patient care delivery while reducing nurses’ documentation load and increasing the time available for caring for various patient populations (Munyisia, Yu, & Hailey, 2012).

During my clinical rotation at the Veterans Administration (VA) Hospital in Birmingham, Alabama I was able to manage the task of developing an effective electronic documentation template for the Ambulatory Surgery Facility (ASF) within the VA hospital. The ASF focuses on providing surgical, diagnostic, and preventative procedures in a same-day care setting. This facility offers veterans the convenience of having procedures performed safely outside of the inpatient hospital setting.

The ASF at my precepting healthcare facility used multiple forms of nursing documentation including both hardcopy and electronic methods. Oftentimes the hardcopy nursing notes would be discarded after the information was entered into the Computerized Patient Record System (CPRS). The task to develop an effective electronic nursing note that would eliminate the need for duplicate documentation on hardcopy forms and decrease the amount of time spent charting was initiated.

When beginning my process for change in the ASF, I used Lippitt’s Change Theory as guide. Lippitt’s theory is comprised of four elements; assessment, planning, implementation, and evaluation. These are the essential elements of a planned change. Planned change is focused, deliberate, and collaborative in bringing about needed modifications. Lippitt’s theory focused on the role of the change agent. In this theory information is constantly exchanged through...

... middle of paper ...

...reed that the new note streamlined all of the needed information to one place which made their patient care delivery workflow smoother. There were also minor revisions needed such as the addition of diabetic glucose results, designated driver contacts, and pre-operative sedation medications used. After theses revisions, I completed another workflow assessment of the ASF and found that the average documentation time was approximately 12 minutes.

The new electronic ASF note has reduced the documentation time 40% in the unit. There will always be room to grow and further develop this documentation tool. For now this tool will continue to be used within the VA’s ASF with the hopes of increasing the amount of time spent on direct patient care. The introduction of this new electronic note assists in the VA’s mission of delivering optimal patient care to America’s heroes.