Redundancy in Nursing Documentation

Being an RN working in hospital on Medical, Surgical and Neurological floor, I have the chance to use several healthcare technologies. My floor specializes in strokes, we have patients coming from emergency rooms once they stabilize. The use of technology in the healthcare sector has been of great good in making work easier and more efficient at all levels. Most importantly is the information technology in the healthcare department, which aids in the proper and safekeeping of patient’s records as well as a well-sequenced medical follow-up of the patient. Aside from assisting in data arrangement and records keeping for the nurses and doctors, technology in health care also helps in giving patients an assurance that they are in safe hands of concerned medical practitioners (Montalvo, Dunton & American Nurses Association, 2007). The most commonly used pieces of technology in the health system is the Electronic Health Record, which is used to store patients’ data electronically. However, much as technology has brought benefits in the medical fields, there have been shortcomings raised concerning this issue of this electronic health record. 

Concerns raised....

Redundant Data

1.     The perfect example of a failure is the redundancy of patients’ documentations, and this is due to multiple documentation of a particular patient in the name of checking up on the patients. With the health center requiring nurses to check up on their patients within time intervals, medical practitioners are most likely to double record patients’ information and thus posing a problem. By having double documentations of patients, errors can quickly arise from these documents when administering medical care or referral services, and in our field, such errors could lead to fatal problems. See, documentation is useful and necessary as it makes record keeping easier, however, to some extent such as this case, it is an error which should not have to occur at all in the healthcare sector. This redundancy in record keeping is the foundation of a future mistake by the doctors and other medical practitioners (Montalvo, Dunton & American Nurses Association, 2007).

2.     Redundancy in documentation results in wrong medication, as already pointed out, double documentation presents an error in the records of the patients, which then causes the medical practitioner to administer the wrong medication. Due to electronic health records, the nurses tend to report the patients’ health in the electronic device in a span of time advised to them by the doctors’ in charge, it is as a result of this that the documents are doubled. Through these records, the doctor is then able to administer the medications to the patients, but now, due to the redundant case in these documents, the medical practitioner will be faced with the challenge of figuring out the right data. These false data are dangerous, particularly as it is the lives of human beings that are on the line and not just experiments. Wrong or multiplied information on patients is a serious flaw as the medication of the patient depends on it, meaning that the medics can easily give the wrong medication to the right patient as a result of poor documentation (Schumaker & Reganti, 2014).

3.     Aside from wrong medication, redundant documentation tends to confuse the medical practitioner on which is the correct information for the patient in question. It is only natural that the doctors get a little confused with the data presented to them by the nurses on the electronic health record especially when there are multiple of them. For instance, if the data entered in the system clashes with the same data only different information concerning a similar matter, the doctor will be at a lost as to which information is correct and which one is not (Schumaker & Reganti, 2014).

Such errors, however little they may look pose a challenge and more so, questions the professionalism of the nurse in charge, but most importantly, this problem points a finger in the kind of technology used for documentation. The redundant information entered in the computer is as a result of repetition and not an update on the computer on the patients’ health so that when the doctors want to check on the progress of the patients’ health, they are lost as to which information is correct (Schumaker & Reganti, 2014). However, minor the problem may sound, it should be noted again, that medical centers deal with the lives of people and therefore no room for errors or electronic failures which are why a possible solution should be underway for this problem. The information technology team in the health care center should be able to come up with an ultimate solution to this issue so that no future mistakes are made on the health of these patients. The best step to take to avoid any more errors is to come up with a better system of communication that will help reduce cases of redundant documentations. (Montalvo, Dunton & American Nurses Association, 2007).

Solutions to the problem...

• The information technology team in the health care center should come up

  

  Healthcare Integration Flow

  with a better and organized format of the electronic health record so that there is uniformity rather than separate and different comment on the patient’s health. This change will only classify the information based on the problem and the progress as recorded by the nurses instead of having a full range of slots for many people to fill in the report. By having this new arrangement, there will be no confusion, if anything, there will be better management of data and information on all the patients in the health center (Montalvo, Dunton & American Nurses Association, 2007).

• Following this new arrangement in all the healthcare centers will improve the efficiency of their work and how they deliver their services. Clear and up to date information on all the patients is an assurance to the physicians and nurses if only they choose to adopt this new idea and conduct some few changes in the electronic health record. As I have already pointed out, precision is vital in this field since the players do not have the luxury of making any errors involving the health of their patients (Montalvo, Dunton & American Nurses Association, 2007).

Medication Synchronization

• The other alternative solution to this problem is to have physicians and nurse coordination in the care of severely ill patients, although not entirely biased to the chronically ill. This coordination will reduce the number of documentation under this particular patient, which otherwise leads to confusion. By having this synchronization in the medical care of patients, there will be reduced documentation which will benefit all the physicians and nurses that are taking care of the patient (Montalvo, Dunton & American Nurses Association, 2007).

• Aside from helping the medical practitioners, this improvement will help with the swift recovery of the patients since no errors are likely to occur in their health administration process. Therefore, this solution will go a long way to help with the efficiency of the work done by both the nurses and all the doctors that are involved in the medical procedure of the victim. It is, therefore, very advisable that the all the physicians and the nurses be informed on the benefits of adopting this new coordination for their benefits as well as quicker recovery of the patients (Schumaker & Reganti, 2014).

• The other solution that could help solve the redundancy in documentation problem is by standardizing the care strategy in the electronic health record. This means that the information technology team should come up with a strategy to be used by the nurses on duty which will have a similar care approach for all patients so that there will be proper patient care and reduced redundant documentation. In this case, the nurses will have to engage with the patients and the physicians so as to offer maximum care to the patients and reduce the documentations necessary. This communication will be in synchronization with the key players in this category so that there will be no need for too much documentation in the electronic health record. See; initially, everyone had to document their discoveries and conclusion, leaving the other to do the same, thus causing a clash in their reports on the patients’ data. But with this new program, there will be better management of such information and thus reduce the efforts required by the physicians to figure out which report will be used in medication. Aside from the reduced documentation, the patients will get to experience better care by the nurses as there will be proper communication within the medical channel (Montalvo, Dunton & American Nurses Association, 2007).

Conclusion...

Using electronic health record means that the nurses on duty have to fill out documentation before leaving for their shift, and this means staying a bit longer after their shift before going home. By involving the information technology office in this matter and using the above-stated solution, nurses will be able to enjoy the luxury of going home at the expected time due to reduced documentations. So, having some few changes made on the current electronic health record will bring a whole lot of improvement to the nurses in the healthcare sector which will go a great deal to help them. Aside from benefiting the nurses, the doctors will also have a short time to figure out the problem that is affecting the patient due to the reduced records. Most importantly, the safety of the patient is guaranteed through this new improvement in the healthcare industry. The nurses will have a direct contact with the patients and get their first-hand feedback themselves, thus giving them a chance to fill out the correct and accurate documentation on the health of the patients.  

References

Montalvo, I., Dunton, N., & American Nurses Association. (2007). Transforming nursing data into quality care: Profiles of quality improvement in U.S. healthcare facilities. Silver Spring, Md: Nursesbooks.org, American Nurses Association.

Schumaker, R. P., & Reganti, K. P. (July 01, 2014). Implementation of Electronic Health Record (EHR) System in the Healthcare Industry. International Journal of Privacy

Sewell, J. (2016). Informatics and nursing: opportunities and challenges. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.