Confusion to Creation of a Computer Charting Council

Thursday, March 10, 2016
Veracruz B/C (Coronado Springs Resort)
Amanda Thier, MSN, RN-BC , Baylor Scott and White Heart and Vascular Hospital, Dallas, TX
Megan Ramos, BSN, MSN, RN , Baylor Heart and Vascular Hospital, Dallas, TX

Handout (760.2 kB)

Purpose:
The implementation of the Electronic Health Record (EHR) system presented many struggles and challenges throughout all nursing departments. Although mandatory education was offered, multiple audits revealed the need for a drastic improvement throughout all units.

Relevance/Significance:
The Clinical Practice Council initiated the EHR council to disseminate quality improvement updates, promote patient safety, and implement a culture of consistent charting. A shared governance approach dedicated to leveraging technology to enhance the delivery of nursing care was established and executed.

Strategy and Implementation:
The nursing staff identified committee leaders, created a council charter, and defined project milestones. Multiple avenues of communication were utilized to disseminate the education materials. Monthly tip sheets are centrally placed and a specific EHR binder is located on every unit as a reference guide. Mass communication via emails, timely concurrent review, and unit specific badge cards made for every nurse are a few examples. Despite the major technology upheavals during the implementation of the EHR, the hospital continued to sustain successful practice by maintaining above average patient satisfaction scores and experienced an absolute zero decline in hospital core measures. The EHR council continues to promote a standardized charting practice, and support to all nurses through continuous education initiatives, so a patient centered culture is sustained.

Evaluation:
To evaluate the council's effectiveness and nursing competency related to the constant technological advances, continuous audits are completed by informatics leaders to identify gaps in training and develop effective educational approaches.

Implications for Practice:
Implications for continuous execution consists of active involvement from all nursing departments and monthly council meetings to discuss audited data, staff performance, and informatics updates. Accessibility to informatics experts are offered to give frequent informational in-services.