Nurses have told the patient s story for

FEATURE: Nursig Essetial Elemets of Nursig Notes ad the Trasitio to Electroic Health Records The Migratio from Narrative Chartig Will Require Creativity to Iclude Essetial Elemets i EHRs. By Marjorie M. Heizer, PhD, PNP-BC, CRNP Keywords Chartig, documetatio, ursig care, computerizatio, electroic health record, EHR. Abstract Nursig otes have historically told the patiet s story of ursig care durig a hospital stay, but techology ad treds i healthcare require coversio of paper to electroic health records (EHR). The purpose of this study was to explore what cliical urses believe are essetial elemets of ursig otes, ways that these data are documeted ad barriers to documetatio. This qualitative study used four focus groups. Twety-four registered urses idetified themes of evidece of care, quality issues, iteractio patters, clarificatio ad the picture of the patiet. Barriers to documetatio were time, legal issues, defesive chartig, sidebars ad family/patiet behavior. Fidigs suggest that the trasitio to EHRs will provide solutios to time-itesive chartig ad allow for detailed task check-offs. However, psychosocial characteristics ad idirect care activities ot quatified o checklists also are ecessary for uderstadig the patiet experiece. The migratio from arrative chartig will require creativity to iclude essetial elemets i EHRs. Nurses have told the patiet s story for decades i the form of writte arrative ursig otes ad the verbal shift report. The advet of paper flow sheets ad checklists over the past two decades streamlied the data recordig process for may specialty ad acute-care uits. However, improvemets i computer techology ow support the implemetatio of cliical documetatio ad iformatio systems across all healthcare disciplies. This move to computerized systems makes it ecessary for ursig ad allied health professioals to reframe their thikig about recordig the patiet s story. Commoly held beliefs amog some urses, as explored i this study, are the eed to tell the patiet s story, explai the problems ecoutered ad covey ideas that are ot quatifiable for a computer etry system. Despite these beliefs, patiets may be better served whe urses give up the writte arrative chartig ad ivest their eergies ito electroic health records (EHR). Complicatig this trasitio are research studies that support coflictig beliefs ad practices related to ursig documetatio. 1-5 Nurses are reluctat to use computers because they feel that it will www.himss.org volume 24 / umber 4 FALL 2010 jhim 53

either take them away from the bedside, or because covetioal methods of chartig are easier ad more ituitive to use. 2,6 Howse ad Bailey reported that urses, historically, have resisted documetatio ad held egative views of chartig. 7 Tapp also described urses views o the ihibitors to chartig. 8 Surprisigly, lack of computer literacy did ot appear to be a issue. 9 The major barrier may be resistace to the idea of computerized documetatio systems. Such cocers provide a ope area for research ito the critical elemets of the arrative ursig ote, oe of the idicators of care give to patiets. Although fudametals of ursig textbooks give guidelies for chartig, research ad theoretical essays o the cotet of the ursig ote are early abset from published literature. However, Saba ad McCormick address this theoretical perspective o ursig documetatio i their publicatio o ursig iformatics. 10 These issues stimulated the followig research questios: 1. What do urses believe are the essetial elemets of a ursig ote? 2. What are the ways that urses commuicate their ursig work? 3. What prevets urses from documetig key issues i the patiet chart? These questios framed a research project to traslate the essetial elemets of a ursig ote ito a format suitable for iclusio ito a EHR. The researcher desiged a qualitative study to idetify the essetial elemets of arrative ursig otes as described by registered urses i the cliical settig ad to explore the trasitio of arrative otes to the EHR format. The study addressed three research questios ad focus group methodology was used to collect the data. BACKGROUND Cliical documetatio across all disciplies, whether arrative, computerized or a combiatio of both systems presets a ogoig challege i healthcare. The terms chartig, arrative chartig, ursig documetatio, arrative otes ad ursig otes are used iterchageably ad may be regarded as idetical i meaig. The chage from arrative otes to EHRs is occurrig ow ad directly affects the future of the healthcare system i the Uited States. This trasitio presets multiple challeges to health providers ad the hospitals ad cliics i which they are employed. The earliest published research o ursig otes dates to 1964, whe Walker ad Selmaoff reported the fidigs of their exploratory study of the ature ad uses of the otes. Nurses cosidered chartig as a istrumetal fuctio of ursig (p 120) without sigificat status. Furthermore, urses otes were ot deemed a effective meas of commuicatio amog iterdiscipliary ad multidiscipliary staff. 11 Walker ad Selmaoff also oted that documetatio of the patiet s care ad progress by urses, or the story of ursig care, was iadequate i quality ad quatity. Nurses reported satisfactio with the existig practice, eve with miimal time spet i chartig ad miimal cotet i the otes. However, omissios i documetatio were idetified as a serious ad frequet problem. Walker ad Selmaoff theorized that verbal commuicatio with hadoffs, ogoig updates, ad the shift report may have supplemeted writte documetatio. 11 Nearly three decades later, Tapp coducted a grouded theory study with registered urses i a veteras hospital o the ihibitors ad facilitators of ursig documetatio. Fidigs suggested that ursig lacked a distict professioal idetity ad laguage (p 238) as perceived by the participats. 8 Documetatio was deemed iaccurate, icomplete ad icosistet, addig to its lack of credibility ad value. Tapp foud that accurate documetatio was itegral to defiig cliical ursig The movemet from a arrative system of chartig to a EHR system requires major chages i midset, kowledge, performace ad skills. practice ad substatiatig that ursig care had occurred. Such commuicatio liked practice to both research ad educatio. Brooks aalyzed ursig documetatio i terms of describig the actual work of ursig ad compared verbal descriptios of care issues with the writte documetatio from the same patiet charts. She also foud that urses were strugglig with challeges i streamliig ad codesig documetatio i case-maaged systems ad maaged care eviromets. Her fidigs supported the eed to ivestigate ad refie ursig documetatio practices to reflect ad capture the holistic ature of ursig care. 12 The essetial elemets of ursig otes were rarely addressed i the cliical or research literature. Refereces to the actual cotet of chartig were related to the format of the ursig process categories or completed tasks. However, the idetificatio of the essetial elemets of ursig care is importat to the trasitio to a EHR system. The movemet from a arrative system of chartig to a EHR system requires major chages i midset, kowledge, performace ad skills. 13 I additio, providig a traslatio of the required cotet areas ad documetatio eeds is crucial to the plaig ad implemetatio of a high techology EHR system. METHODOLOGY Qualitative research desig uses laguage to explore meaigs rather tha umerical or quatitative data. The researcher is ivolved with participats who ca provide arrative cotet to explai their experieces with the topic ad descriptios of situatios. Focus groups are a qualitative method i which participats respod to questios about their experieces. This study used focus groups of urses to idetify curretly held beliefs regardig the essetial elemets of ursig otes. As a qualitative research method, focus group iterviews provide a veue for sesitive discussio of idividuals beliefs, perceptios, ad attitudes. 14-15 The subjective ature of focus group methodology leds itself to explorig the beliefs ad attitudes of professioal urses who shared their experieces with colleagues i a comfortable, o-threateig eviromet. Focus groups facilitators ecourage participatio ad ope dia- 54 jhim FALL 2010 volume 24 / Number 4 www.himss.org

Table 1: Questios for Focus Groups. From Brooks, JT. A aalysis of ursig documetatio as a reflectio of actual urse work. Medsurg Nurs. 1998; 7(4):189-196. logue, clarify resposes, ad redirect to questios without ifluecig cotrol or cofirmatio of their ow persoal beliefs. 16 The group iteractio helps to clarify the views ad meaigs expressed by idividual participats i each sessio. The resultat arratives, therefore, reflect more coformity about the issues rather tha the stregth of idividual opiios. However, the use of several focus groups ca stregthe the outcome as the rage of resposes across the groups ca demostrate agreemet o the relevat issues. 15,17 This agreemet gives evidece of credibility of the meaigs ad the themes ucovered i the study. Although reliability ad validity of data are critical to quatitative research, credibility is a key factor i demostratig rigor i qualitative studies. Persos who are experts i the field are selected for participatio i the focus groups ad size of each group is limited to allow for full discussio of the topics. The resposes are recorded ad documeted o flip charts or large easel boards for cofirmatio ad feedback from the participats before each sessio is closed. Historically, focus group methodology has bee used as a market research strategy. 14,18 The method has bee foud to be beeficial i ursig research to shape ad develop ursig educatio strategies, evaluate cliical practice goals, explore ad discover patters, ad iterpret behaviors, feeligs ad meaigs. 15,19 Completio of the focus group ad aalysis of group data followed similar processes as are used i qualitative studies. Cotet aalysis of the data usig a iductive approach was doe for developmet of thematic categories util data saturatio was achieved. Data saturatio occurs whe repetitio across resposes is oted ad o ew iformatio is added by participats i the sessios. DATA COLLECTION The study was coducted i a urba hospital settig i the ortheast regio of the Uited States. The hospital s Istitutioal Review Board (IRB) approved the proposal. A research team composed of the primary ivestigator, a ursig research coucil task force, ad two facilitators plaed the implemetatio of the study. All members of the hospital s professioal ursig staff were potetial subjects. Usig a radom umber table, 150 urses were selected from the total of 480 registered urses o the staff. The pla was to recruit at least 30 urses from the professioal staff to represet all areas of specialties ad uits. Sice patiet cesus was high, staffig patters were ot flexible ad urses eeded to come i to the settig outside of workig hours, a large pool of potetial urses were selected. The urses were mailed letters ivitig them to participate i the focus groups, alog with demographic data forms ad iformed coset forms. The coset forms icluded a offer of moetary compesatio for participatio i oe of the group sessios. Thirty urses agreed to participate ad completed the forms. Demographic data sheets ad coset forms were retured prior to the start of each sessio. Follow-up phoe calls were made to each urse to verify receipt of the forms ad cofirm the date ad time for the focus group sessio. The fial participat groups icluded 24 urses (21 females ad three males) from all major specialty areas i the hospital. The age rage was 23 through 56 years, with a mea age of 41.6 years. The average for years as a registered urse was 15.3. Focus groups raged i size from five members to eight members ad each group met for two hours. The focus groups were scheduled durig the staff s o-workig hours. Five focus groups were plaed; however, oe early sessio was caceled due to miimal membership ad high staffig eeds at the hospital. Scheduled participats i that group joied oe of the remaiig groups. The four focus groups were held at various times throughout the day over a three-week time spa. The rooms www.himss.org volume 24 / umber 4 FALL 2010 jhim 55

chose for the sessios were coferece rooms that were welllighted ad furished with comfortable chairs. Refreshmets were provided for all participats at the coclusio of each sessio. Both facilitators for this study were registered urses with strog cliical backgrouds ad members of the quality maagemet departmet. They were traied i focus group facilitatio by the researcher ad a experieced focus group facilitator from the departmet of orgaizatioal staff developmet. The facilitators of the focus groups prepared for two moths prior to iitiatig the study. The researcher opeed each focus group sessio with a itroductio to the study ad the facilitators ad preseted guidelies to be used i the sessio. The facilitators the coducted the focus group ad at the ed of each sessio, the researcher retured ad thaked the participats. A compesatio beefit of $25 was distributed to each participat at the coclusio of the group sessio. Modificatios of Brooks 12 questios guided the focus groups for this qualitative study. (See Table 1.) The questios were set to each cofirmed participat at least oe week prior to the scheduled sessio. The questios were also prited o poster boards that were promietly displayed i the coferece room durig the focus groups. Followig the first focus group, questios were reordered to facilitate the group participatio i the fial three groups. Resposes to the questios were tape-recorded for trascriptio of cotet. Meaigs ad beliefs were clarified with participats throughout the sessios ad prited o flip charts for visible validatio. The facilitators ad primary ivestigator met followig each focus group to review the process ad cotet of the group sessio. The research team also met cosistetly throughout the study ad discussed themes that arose from each focus group. Data saturatio occurred durig the fourth focus group sessio. Data were the trascribed verbatim from the tapes ad flip charts ito a arrative for each group. The primary ivestigator ad members of the research team read each of the trascriptios idepedetly at completio of the focus groups. FINDINGS The first focus group questios asked were Whe you documet, who do you thik reads the otes ad what do they look for? Respodets idetified healthcare delivery team members by their positios or fuctioal roles. These icluded urses, physicias, studets, residets ad acillary staff. A secod group of persos idetified were those idividuals or groups who provide iteral ad exteral oversight to care delivery: care/case maagers, risk maagers, utilizatio review coordiators, Joit Commissio teams, isurers ad quality assurace persoel. The legal system surfaced as a separate ad importat etity i all four groups ad was the first respose of oe focus group. Aother focus group, with eoatal ad pediatric staff, idetified the parets of mior childre as potetial readers of the documetatio, yet o group members cosidered the actual patiet as oe who reads the chart. Themes. Although the ursig process formed the framework for the orgaizatio ad delivery of care, five major themes formed the essetial elemets of a ursig ote: evidece of care, quality issues, iteractioal patters, clarificatio of orders ad the picture of the patiet. Evidece of care icluded actual care activities, tasks performed, discharge plas, medicatios ad treatmets, referrals, The focus groups believed that the commuicatio patters, cotext ad cotet of iteractio were importat to the uderstadig of the patiet, family ad care eeds. educatioal itervetios, chages i protocols, resposes to itervetios ad acuity issues. This cotet primarily reflected physiological ad educatioal eeds. The daily hygiee, teachig sessios, therapeutic treatmet regimes ad vital sigs comprised much of this theme. The secod theme, quality issues, ecompassed thoroughess i delivery of care, the timig ad sequecig of care, ad cotiuity across time periods. The followig of stadards of care, the documetatio of ratioales for care decisios or chages, setiel evets, outcome evidece ad updatig care with the expasio of a care pla arose uder this theme. Iteractio amog various groups ad idividuals surfaced as the third theme. The focus groups believed that the commuicatio patters, cotext ad cotet of iteractio were importat to the uderstadig of the patiet, family ad care eeds. The iteractios icluded, but were ot limited to, healthcare staff ad patiets, patiet ad family cotacts with other family members, ad patiet cotacts to acillary help. Commuicatio of ursig staff with physicias or other healthcare specialists, ursig staff member to aother staff member, or ursig staff to support services provided aother patter of iteractios, oe of professioal cotacts. Clarificatio of specifics of care, uclear or umet patiet eeds ad details i the descriptios of problems were grouped together. Icidets or chages i treatmet plas directed by idividual patiet eeds clustered with the clarificatio theme. The picture of the patiet, metioed i these exact words by urses i two differet focus groups, captured urses descriptios of holistic assessmet ad the complete patiet s experiece i the documetatio. They spoke about their ituitive kowig ad uderstadig of the eeds of the patiet i their daily work. Value of documetatio. Other focus group questios addressed what the participats saw as the value of documetatio, what is most importat, ad for whom. Respodets from the groups said that the value was related to uderstadig the patiet experiece; commuicatig eeds, ethical issues, ad collaboratio processes; recordig the delivery of care, reviewig activity ad prevetig duplicatio of services, otig social issues ad providig evidece for accoutability ad protectio from liability. The most importat elemets emphasized were basic care, the evidece of commuicatio, ethical issues, safety measures, collaboratio with others ad social problems. There was agreemet 56 jhim FALL 2010 volume 24 / Number 4 www.himss.org

across all groups that there was value for the healthcare team members, the family ad the patiet. Participats oted that commuicatio might occur i verbal ad other writte format, ot just i chart documetatio. Their examples icluded had-offs at chage of shift ad summaries, uit commuicatio books, ad paper reports as other writte sources. Verbal reports, team meetigs, team rouds, ad ursig rouds provided other importat sources for commuicatio. Accuracy. The questio about accuracy i chartig, How accurate do you thik that documetatio is as a reflectio of ursig work doe durig that shift? brought discussio about the miimal reflectio of actual ursig work that ca be coveyed i writig. Some focus group participats said that ursig is active work ad writig reflects oly a small percetage of the ursig care give. Group members poited out idirect care activities. Examples icluded cotacts o the phoe with families, physicias ad departmets; psychosocial iteractios with patiets ad families, carig for a difficult patiet, time assistig physicias ad time spet lookig for forms or idetifyig the correct form for the problem. Nurses believed that curret documetatio udervalued the work doe ad did ot show the uaces of care. Oe group member said that the documetatio was ot very accurate sice the urse is spedig more time doig tha writig. All of the focus groups agreed that documetatio uderrepreseted actual ursig work. Barriers to documetatio. Barriers to documetatio were idetified as limitatios i time, legal ramificatios, the perceived eed for defesive chartig, sidebar stories ad variatios i family ad patiet behavior. Several urses oted that chartig forms varied across uits ad access to forms was ofte difficult because of differeces i filig systems ad availability of materials. The time spet idetifyig the correct form ad the locatig the form created frustratio ad used time that could have bee spet with patiets. Cosequetly, the issue of time costrait was a commo theme throughout all of the group discussios. SUMMARY Focus group themes that arose from the questios that dealt with the essetial elemets of documetatio were evidece of care, quality issues, iteractioal patters, clarificatio of orders ad the picture of the patiet s experiece. The focus groups idetified the ursig process as the framework for achievig the documetatio elemets. The process icluded assessmet, diagosis with pathway developmet ad care plaig; itervetios, icludig tasks ad teachig; patiet ad family resposes to care, chage of patiet status ad reassessmet. Participats also said that ursig is doig ad the writte documetatio i the chart reflects oly a small percetage of the care give. Time costraits were the most frequetly oted barriers to documetatio. LIMITATIONS Several limitatios to a focus group study were addressed durig the data collectio ad aalysis. The facilitators were aware of the group thik potetial, where group members are less likely to share idividual feeligs or beliefs ad ted to follow the group cosesus. 19-20 Efforts were made to refocus participats to idividual resposes o the issues with group discussio. Attempts by more assertive members to moopolize group discussio were also maaged by facilitators, ad all members were ecouraged to share their ow viewpoits ad cotribute examples for clarificatio. 14 Nurses believed that curret documetatio udervalued the work doe ad did ot show the uaces of care. Oe group member said that the documetatio was ot very accurate sice the urse is spedig more time doig tha writig. Although the research team experieced o difficulty i accessig staff voluteers for participatio i the study, patiet acuity ad cesus icreased durig the three-moth time period i which the groups were scheduled. Cosequetly, a few participats withdrew from their idividual groups because of work schedule coflicts. The first plaed focus group sessio was cacelled withi 24 hours of its startig time as staffig eeds escalated whe the patiet cesus icreased o several uits. Those urses who were available for aother scheduled group arraged to participate at a differet time. The variety of specialties represeted i the focus groups did ot appear to be a problem as discussios were ope, cadid, ad respectful. Usig focus groups of urses from oe medical ceter limited the fidigs to oe particular urba settig, which may ot represet urses i other regios or i other acute care agecies. CLINICAL IMPLICATIONS The redesig of traditioal cliical records ito a EHR system presets multiple opportuities for improvemet, both i what urses preset i the patiet record ad how it is preseted. Focus group themes of the urse work beig iaccurately reflected i the record may be the mai reaso behid some urses resistace respose to computerized documetatio. The most dramatic chage from arrative otes to EHR systems is the stadardizatio of data elemets ad termiology. 10 The curret electroic format focuses o the capture of orders or actios, documetig the completio or result of a actio ad ogoig documetatio of objective assessmet fidigs. 21-22 Opportuities to streamlie commuicatio ad documetatio, decrease the amout of duplicative data etry, add to the evidece base for practice, ifluece policy-makig ad improve the stadard of care are iheret i these systems. EHR systems will adequately meet ad ideed ehace the completeess of documetatio of basic care, clarificatio of orders, quality ad safety elemets, ad the ursig process chartig requiremets as defied by the focus groups ad supported by the literature. 21-24 However, curret systems fall short of the idetified eed to commuicate the collaborative care plaig ad goal-directed, outcome focus of itegrated care delivery. The trasitio from www.himss.org volume 24 / umber 4 FALL 2010 jhim 57

siloed, disciplie-specific chartig to a truly itegrated record is essetial 21 yet usettlig for some healthcare professioals. The requiremet for a commo vocabulary ad approach to the computerized record may uify specialties, but also blur the lies betwee them. There is a critical eed to defie the role of urses as members of a itegrated team. The team must develop trust ad respect betwee ad amog care providers i order to share, build upo ad complemet the assessmet fidigs ad evaluatio of patiet-specific goals. 10 The urse who prefers hadwritte documetatio rather tha EHRs to defie ursig practice will fid this to be a difficult adjustmet. The urse who chooses to give the patiet s story durig hadoff or shift report rather tha fid a way to reflect the story i the EHR has a opportuity to improve a icomplete patiet record. This perspective addresses the ature of urses cocers with tellig the story as commuicatig aecdotal evidece. Wiltshire differetiated verbal storytellig from writig a arrative, which he described as a reflective, thoughtful, ad theoretical costructio. The arrative implied a more equivalet positio betwee the urse ad the patiet (p 81) likig empirical ad theoretical cotet i documetatio. 25 Defiitios of stadards of care ad assessmet criteria will provide opportuities to streamlie curret care processes ad to uderstad why these processes are performed the way they are. Regulatory ad istitutioal documetatio requiremets have ad will cotiue to provide the framework for defiig documetatio stadards. Although curret EHRs sufficietly meet the urse s eed to documet themes of evidece of care, they fall short whe reportig the story that adequately depicts the cotext of huma iteractios, emotioal ad social perspectives, ad sequece ad timig of actios. Focus group feedback also oted who the urses thought did ad did ot read ursig documetatio. Cliicia participatio is critical for expert iput i all aspects of defiitio of cotet ad cotext of data elemet documetatio. Major vedors are movig towards itegrated ad automated documetatio systems especially for case maagemet. 26-27 Shared data elemets i the patiet record afford icreased exposure of ursig otes to other disciplies otes ad vice-versa. This exposure, combied with regulatory-drive requiremets for improved reflectio of idividualized care i documetatio, will move healthcare istitutios toward true itegratio of iterdiscipliary teams ad ehace the traslatio of research ito practice. 28 FUTURE RESEARCH The traslatio of elemets ito EHR format is i process. Because of the federal govermet s commitmet to promote atiowide adoptio of EHR systems, it is likely that the tred to traslate ursig otes to EHR format will cotiue to grow. 21 Future research icludes a gap aalysis of defied, required elemets of ursig documetatio ad the ability to capture The redesig of traditioal cliical records ito a EHR system presets multiple opportuities for improvemet, both i what urses preset i the patiet record ad how it is preseted. Focus group themes of the urse work beig iaccurately reflected i the record may be the mai reaso behid some urses resistace respose to computerized documetatio. these i curret itegrated systems. Acceptace ad realizatio of the eed to move from disciplie-specific documetatio to iterdiscipliary health records, ad ideed, to a truly itegrated, goal-directed record of a cotiuum of care are ecessary for successful adoptio of EHR systems. Nurses workig collaboratively with other cliicias must ow create a multidiscipliary, itegrated database. The database requires the desig of a care team ad a uderstadig ad acceptace of the idividual ad collaborative ature of each disciplie ivolved i the team to effectively ad efficietly coordiate ad maage the cotiuity of care. 29 The urse, as a cetral player i this team, must be able to clearly articulate the urse s role ad resposibilities as defied by the ursig process. Special attetio to the psychosocial, ethical, ad commuicatio/ iteractio documetatio eeds, as defied by the focus groups, will be eeded to facilitate the trasitio from the arrative format to a accepted olie record. CONCLUSIONS Takig ito accout the resposes of the registered urses participatig i this study s focus group discussios, the psychosocial characteristics ad idirect care activities ot quatified o checklists are ecessary for uderstadig the patiet experiece. Although this was oe study with oe group of registered urses i oe medical ceter, cliical aecdotal feedback from urses i other areas of the coutry reflect similar themes as those that emerged from this focus group study. Further exploratio of these cocers will assist medical ceters i desigig ad/or implemetig programs that meet the madates ad fit their ow istitutioal models. The trasitio from traditioal arrative otes to EHRs will require a adaptatio of free text chartig i EHR software programs, stakeholder buy-i ad commo laguage to capture critical descriptive details from healthcare providers. The Natioal Istitutes of Health (NIH) reported that implemetatio of a successful electroic record format for cliical documetatio had the potetial to save more tha oe-fifth of ursig time. 21 The migratio from arrative chartig will require creativity i desig so that essetial elemets of ursig otes idetified by urses are icluded i EHRs. The process of refiemet must cotiue util accurate ad comprehesive represetatio of ursig care 58 jhim FALL 2010 volume 24 / Number 4 www.himss.org

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