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Changes in Clinical Documentation Essay

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Updated: Mar 22nd, 2021

Nursing Practice Identification

Charting by exception, the record-keeping or paper documentation method we use currently in my clinical setting (Intensive Care Unit) to keep key patient clinical information based on predetermined standards of practice requires change for improved patient outcomes.

Nursing Practice Description

Clear and elaborate nursing communication contributes to better patient outcomes. In the charting by exception method, the nurse records key information about the patient’s progress on a chart (Syed et al., 2013). The chart usually captures the patient’s medical history, assessment outcomes, lab results, and the medication received, among others. It is designed to reduce clerical work through the documentation of findings that deviate from the baseline data. Therefore, the method is quicker as data thought to be unfavorable or already recorded are not documented. In addition, the abatement or aggravation of the patient’s condition is easily identifiable through a shorthand notation made on the chart.

Why Nursing Practice Needs to Change

Although charting by exception usually gives a complete patient record, the shorthand notation implemented without appropriate flow sheets creates information deficits, increasing the medication error risk. Patient records with little explanations or health checks lacking pertinent information could amount to negligence on the part of the nurse. Moreover, providing an incomplete picture of the patient’s condition affects patient safety. A complete patient record contains current information about his/her condition as well as indicators of future health changes to inform subsequent interventions.

A secondary reason for adopting an Electronic Health Record (EHR) to replace the current paper documentation is to enhance the timely retrieval of patient records to support care coordination and efficiency. This paper addresses the following PICOT question to support a practice change: in ensuring a timely retrieval of patient records, does electronic documentation, compared to paper documentation, enhance quick access to patient data for coordinated and efficient care?

Key Stakeholders

The implementation of the charting by exception, including the flow sheets, at the unit, involved a multidisciplinary team. Its key stakeholders include physicians, ICU nurses, administrative staff, and laboratory staff.

Stakeholders’ Roles

Representatives from each of the stakeholder groups will play a role in the successful EHR adoption. A physician champion or representative will serve as a link between clinicians and the EHR implementation team. He or she will give input to the developers from a clinical perspective to ensure a physician-friendly EHR program, promote physician buy-in, and keep the physicians abreast of the project’s progress. The physician champion will also support meaningful use practices for the EHR program.

The nurse lead will be a leader respected by fellow ICU nursing staff. The individual will help the developer integrate clinical workflows into the EHR program. As an inspirational leader, the nurse leaders will be expected to influence the nurses to embrace change (EHR). The individual will also strike a consensus among the nurses on issues of nursing workflows. He or she will act as a super-user who will train other nurses after receiving advanced training on the program.

An implementation manager drawn from the administrative staff will oversee the entire project. His or her administrative roles will include monitoring the EHR implementation to avoid delays, ensuring timely procurement of requisite hardware, vendor selection and vetting, and role assignment, among others. The individual will also keep the staff updated on the project’s progress.

The lab lead will be responsible for promoting the EHR program among the laboratory staff. The individual’s input will ensure the application captures all lab workflows and support transition management. He or she will advocate for eHealth and the adoption of EHR in the hospital and address concerns raised by fellow staff.

Evidence Critique Table

Full APA Citation Evidence Strength (1-7) and Evidence Hierarchy
1. Beach, J. & Oates, J. (2014) Maintaining Best Practice in Record-keeping and Documentation. Nursing Standard, 28(36), 45-50. 7 and practice guidelines
2. Shriner, A. & Webber, C. (2014). Attitudes and Perceptions of Pediatric Residents on Transitioning to CPOE. Applied Clinical Informatics, 5(3), 721-730. 4 and prospective study
3. Colligan, L., Potts, H., Finn, C., & Sinkin, R. (2015). Cognitive Workload Changes for Nurses Transitioning from Legacy Systems with Paper Documentation to a Commercial Electronic Health Record. International Journal of Medical Informatics, 84(7), 469-476. 3 and quasi-experimental
4. Razaeibagha, F., Win, K., & Susilo, W. (2015). A Systematic Literature Review on Security and Privacy of Electronic Health Record Systems: Technical Perspectives. Health Information Management Journal, 44(3), 23-38. 5 and meta-synthesis
5. Hawley, G., Jackson, C., Hepworth, J., & Wilkinson, S. (2014). Sharing of Clinical Data in a Maternity Setting: How do Paper Hand-held Records and Electronic Health Records Compare for Completeness?. BMC Health Services Research, 14(1), 547-563. 4 and cohort-comparison

Evidence Summary

One advantage of electronic healthcare documentation is that it enhances the quality and accessibility of clinical records compared to paper-based records. However, an effective transition is needed for a successful EHR implementation. In a study by Colligan, Potts, Finn, and Sinkin (2015), computer attitude scores of most nurses were found to initially correlate with increased workload perceptions during a top-down EHR implementation to replace a paper documentation system. This finding shows that negative or variations in attitudes should be expected during the early stages of EHR adoption. The authors conclude that long-term technical support, coupled with individual-centered training, can support the transitioning and “meaningful use” of EHRs by the clinical staff (Colligan et al., 2015, p. 474).

Meaningful use requires users/providers to embrace best practices in electronic record keeping. Beach and Oates (2014) hold that nursing documentation practices should be aligned to the changing clinician-patient relationship. Drawing on recent public inquiries and legislations such as the Health and Social Care Act, the authors advocate for multidisciplinary collaboration in using EHRs to plan and evaluate care and involve patients as a key aspect of professional best practices.

The collaborative working should extend to the writing of patient records, which should reflect professional standards of the Health and Social Care Information Centre (HSCIC) with regard to terminology, structure, and content (Beach & Oates, 2014). Another suggested best practice in EHR implementation is effective information governance to ensure safe storage and sharing of patient health information to satisfy privacy requirements.

Further, the use of EHRs has been shown to improve the sharing and availability of clinical data to authorized clinical staff. A study comparing hand-held paper records (PHRs) and EHRs in a maternity clinic found that more complete records of “urine culture, glucose tolerance test, nuchal screening, tobacco smoking, domestic violence assessments, and immunizations,” among others, were captured using the EHRs than with the PHRs (Hawley, Jackson, Hepworth, & Wilkinson, 2014, p. 561).

However, records of blood pressure, levels of antibodies, and rubella diagnosis did not differ significantly between EHRs and PHRs with regard to completeness. These findings show that EHRs give quality, complete, and up-to-date antenatal data to improve patient safety. Additionally, electronic documentation facilitates information exchange between providers, as it supports authorized access to the system by staff to retrieve patient information.

A systematic review by Razaeibagha, Win, and Susilo (2015) examined the privacy issues related to EHRs. An analysis of the findings of 55 studies based on ISO standards yielded 13 key aspects of EHR security and privacy. Among the key technical features were “access control, compliance with security, interoperability, policies and regulations, and scalability,” among others (Razaeibagha et al., 2015, p. 26). Technical features that ensure authorized access can protect the privacy of patient health records. In addition, institutional policies and guidelines to govern the use of EHRs can help the provider/clinician attain meaningful use requirements. The interoperability aspect of the systems supports the sharing of patient data securely, billing, and reporting to federal agencies.

Effective management of attitudes and perceptions can reduce resistance to change in clinical settings. In a prospective study by Shriner and Webber (2014), up to 80% of pediatric residents preferred the CPOE tool in the EHR to paper orders a year after its implementation. In contrast, a non-significant number (3.3%) held that the hospital should revert to the paper documentation system. Further, no significant differences were found in the time spent entering admission orders using CPOE vs. paper records 12 months post-implementation.

This finding shows that EHR adaptation by the clinical staff requires adequate technical support and training to make them more knowledgeable and reduce negative perceptions about the product. Therefore, adequate technology resources and ongoing technical support are required for effective utilization of EHRs, especially during the transition period.

Recommend Best Practice

The adoption of EHRs enhances access to complete clinical records, which results in improved patient care and operational efficiency. However, inadequacies associated with the software learning curve during the initial stage of EHR implementation can limit its use (Colligan et al., 2015). I would recommend change management, which is a classic best practice for transitioning staff when implementing new technology.

The concerns of EHR users, including high workload perceptions and attitudes, could be addressed through change management. A successful change management strategy entails defining the business case for the change. For the ICU setting, a unit-level business case could be to enhance physician access to patient records while on call. It also encompasses continuous monitoring of risks and emergent issues, having an effective communication plan to update stakeholders, education and training, and personal counseling to manage concerns and attitudes.

The smaller ICU practice setting should seek to support personal skills and dedication to collaborate and share patient data during EHR implementation. The change management strategy should stress the practical aspects of the new technology to promote buy-in from the stakeholder groups. Wide consultations with the stakeholders right from the planning phase is required to capture lab/nursing workflows and support a smooth transition, as opposed to a top-down approach. Further, post-implementation technical support and training are needed to enable physician practice groups to use other EHR features such as CPOE. Most importantly, a practice-level ownership of the change process and EHR implementation is important, as change is often an intrinsically generated behavior.

Practice Change Model

Kotter’s multi-step change management model is appropriate for the transition from paper documentation to electronic documentation in the ICU practice. The three-phase model requires one to conceptualize change as a “journey for the entire organization” that would transform the current practice, i.e., paper documentation, into an envisioned practice that utilizes technology to support efficiency in care delivery (National Learning Consortium, 2013, p. 4). Its three phases include establishing pro-change conditions, engaging and empowering the institution, and adopting and sustaining the successes (National Learning Consortium, 2013).

Model Justification

An EHR initiative is an impetus for an institutional culture change to reflect the state envisioned by the practice. Kotter’s change model is relevant to the proposed change at the ICU unit because it focuses on changing how people work to achieve and sustain anticipated levels of practice efficiency. The EHR program will replace the paper records currently in use at the ICU unit. It will promote staff effectiveness and efficiency, and therefore, support practice transformation. A holistic ICU practice change must be supported by technology and innovation (Hoonakker et al., 2013). The EHR will not only automate the current paper records, but it will also integrate the ICU processes into improved practice.

Another important dimension of the change model is its focus on people. Managing human resources is crucial to achieving a successful change process because it promotes organizational culture change. Most technology initiatives fail because project leaders do not consider people factors and dynamics in the organizational context (National Learning Consortium, 2013). A change initiative may cause uncertainty, breed the fear of possible job loss, and create negative perceptions towards the technology. One way of overcoming these challenges during the proposed EHR project at the unit is through staff involvement during the planning, execution, and evaluation stages.

Model to Guide Implementation

One of Kotter’s principles is establishing a “vision for the future state” when planning for a change initiative (National Learning Consortium, 2013, p. 6). Moving from paper to EHR would require clear communication of the vision or goals of the project to the ICU staff. The model also holds that one must identify a guiding coalition and create a sense of urgency to create pro-change conditions. Similarly, in EHR implementation, one must identify nurse/physician champions to spearhead the change and create a project plan. Therefore, the ICU unit must define a vision for the change initiative that reflects its goal of achieving a fully automated and integrated EHR system at the unit.

In the second phase, the implementation team is required to engage and empower staff in order to realize a predetermined ‘future state’ of affairs. It further requires constant communication of the envisioned state through vendor demonstrations and staff visits to facilities already using EHR to the stakeholders (National Learning Consortium, 2013). Similarly, in implementing EHR at the unit, staff involvement during system selection and adoption as well as usability evaluation would be considered a best practice. It also requires staff training to equip users with relevant skills, dispel fears related to a possible job loss, and assure them that the initiative is in their best interests.

The final phase of Kotter’s model emphasizes sustaining the changes through staff retraining, technical support, and staff motivation (National Learning Consortium, 2013). This principle can be realized in the EHR implementation at the unit through a feedback mechanism, rewarding key staff, and retraining of staff for improved workflow efficiency.

Barriers to Implementation

The top barrier to the successful implementation of EHRs, as cited by clinicians, relates to the costs versus benefits of the technology (Ajami & Arab-Chadegani, 2013). The failure uses EHRs meaningfully at the facility and practitioner levels mean that the institution may not benefit from the federal incentive program or reimbursements (Ajami & Arab-Chadegani, 2013). EHR adoption requires a major resource investment; hence, it may be a costly undertaking for the smaller practice setting, such as the ICU. Furthermore, there is a feeling that EHRs ultimately benefits the patient and payers, not the providers.

Technical malfunctions and limited interoperability also present another set of challenges to users. The issue of privacy of patient health information is paramount in healthcare settings. Therefore, concerns about the privacy of electronic patient records can be a barrier to effective EHR implementation. Commercial EHR programs are not standardized, i.e., they use different code sets (Ajami & Arab-Chadegani, 2013). This multiplicity of data standards makes it difficult to share or transmit information across multiple platforms.

Institutions implementing an EHR project often lack a well-trained workforce to drive the process. It is essential to have nurse/physician champions skilled in healthcare informatics to inspire staff to embrace the technology. It would be difficult to obtain a consensus among staff over the content or structure of the EHR code sets without having an influential physician/nurse champion. EHR implementation initially disrupts normal workflows within a practice area. Therefore, challenges associated with software used during the early phase of the implementation process may create the perception that the technology is difficult to use and raise calls for a reversion to paper records (Colligan et al., 2015).

Ethical Implications

The electronic health record contains vital information related to the patient. Therefore, while the physician and the facility may own the EHR, the ultimate owner of the data in the record is the patient (Ozair, Jamshed, Sharma, & Aggarwal, 2015). The planning or implementation of the EHR project at the ICU unit has potential implications for the privacy and confidentiality of patient information. Patient health data is protected from other people or institutions unless through his/her consent or a legal requirement.

An interoperable EHR should support information sharing across platforms or between providers. This feature may compromise patient confidentiality if institutions, e.g., insurance firms, are able to access the information. To overcome this problem, in planning for the EHR project at the unit, each user will be assigned a username and password that grants a certain level of access to the patient’s health record based on the individual’s roles.

The EHR project may also be prone to security breaches, potentially releasing patient records to unauthorized people. Portable EHRs contained in mobile devices are vulnerable to hacking when not properly encrypted (Ozair et al., 2015). This issue may arise in the proposed project, leading to unauthorized access to patient records in violation of the privacy policy. The problem could be prevented through data encryption, the use of passwords, and storing data in a cloud (Ozair et al., 2015).

The project could also have implications for system implementation. Successful implementation requires one to involve the clinical personnel in workflow design, choice of EHR, and performance improvement (Ozair et al., 2015). The failure to involve users could result in a dysfunctional user interface, which will reduce efficiency and increase the medical error risk. Prior testing of the EHR application may be necessary to identify malfunctions that may cause practice disruptions during implementation.


Ajami, S., & Arab-Chadegani, R. (2013). Barriers to Implement Electronic Health Records (EHRs). Materia Socio-Medica, 25(3), 213-215.

Beach, J., & Oates, J. (2014) Maintaining Best Practice in Record-keeping and Documentation. Nursing Standard, 28(36), 45-50.

Colligan, L., Potts, H., Finn, C., & Sinkin, R. (2015). Cognitive Workload Changes for Nurses Transitioning from Legacy System with Paper Documentation to a Commercial Electronic Health Record. International Journal of Medical Informatics, 84(7), 469-476.

Hawley, G., Jackson, C., Hepworth, J., & Wilkinson, S. (2014). Sharing of Clinical Data in a Maternity Setting: How do Paper Hand-held Records and Electronic Health Records Compare for Completeness?. BMC Health Services Research, 14(1), 547-563.

Hoonakker, P., Carayon, P., Brown, R., Cartmill, R., Wetterneck, T., & Walker, J. (2013). Changes in End-user Satisfaction with Computerized Provider Order Entry over Time among Nurses and Providers in Intensive Care Units. Journal of the American Medical Informatics Association, 20, 252–259.

National Learning Consortium. (2013). . Web.

Ozair, F., Jamshed, N., Sharma, A., & Aggarwal, P. (2015). Ethical Issues in Electronic Health Records: A General Overview. Perspectives in Clinical Research, 6(2), 73-76.

Razaeibagha, F., Win, K., & Susilo, W. (2015). A Systematic Literature Review on Security and Privacy of Electronic Health Record Systems: Technical Perspectives. Health Information Management Journal, 44(3), 23-38.

Shriner, A., & Webber, C. (2014). Attitudes and Perceptions of Pediatric Residents on Transitioning to CPOE. Applied Clinical Informatics, 5(3), 721-730.

Syed, S., Wang, D., Goulard, D., Rich, T., Innes, G., & Lang, E. (2013). Computer Order Entry Systems in the Emergency Department Significantly Reduce the Time to Medication Delivery for High Acuity Patients. International Journal of Emergency Medicine, 6(1), 20-31.

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