Introduction
Nursing professionals are the information-dependent knowledge workers that play a fundamental role in defining the current evolving healthcare system. Therefore, they must be well-prepared to make critical contributions by exploiting the “proper and timely information” (McGonigle & Mastrian, 2017, p. 10). This paper examines the implementation of a new nursing documentation system and a pivotal role of a nurse leader in the implementation team.
Planning and Requirements Definition
Improved nursing documentation is a vital step in healthcare settings that reflects the awareness level of nurses regarding their roles in providing high-quality care. The rapidly evolving healthcare system requires the most rigorous documentation. By controlling the implementation of current procedural terminology (CPT) codes, one can determine the health IT toolkit’s role in enhancing coding accuracy and completeness, which provides decision support for documentation activities (AHRQ, n. d.). The planning process is primarily based on the staff’s attitudes towards and opinions about the new documentation technology.
Analysis
The analysis phase of the new system development implies that the requirements for the system are separated from a detailed examination of the business needs of the organization. This stage involves the in-depth study of the workflows and business practices. It is essential to analyze the influence of clinical and administrative workflow to successfully implement health information technology. Workflow assessment for health IT toolkit is developed for the planning, design, implementation, and use of health IT in ambulatory care (Digital Healthcare Research, n. d). The analysis might also incorporate the review of new options for changing the business process. The analysis stage is crucial to ensuring an appropriate definition of the software’s overall configuration.
Design of the New System
During this stage, the nursing leader and his team critically consider and verify which data are “required or essential” (McGonigle & Mastrian, 2017, p. 177). The successful implementation of electronic nursing documentation is a core challenge for many national hospitals that need to identify key areas for redesign and modification of their current electronic documentation system. Hence, it is crucial to incorporate documentation standards based on the patient information needed to deliver safe and high-quality care, which, in turn, influences the design to optimize the use of electronic nursing documentation systems.
Implementation
Comprehensive nursing documentation software should be highly prioritized for all hospitals and ASCs. Nursing professionals must be informed of their interactions with electronic nursing documentation to provide appropriate patient care. Nursing leadership must be conscious of the limited knowledge about electronic nursing documentation’s contribution to patient care quality (Hirsch, 2016). The main implementation strategy implies the gradual migration to an advanced EHR system through staff involvement, eliminating paper documentation, and interconnectivity of applications
Post-Implementation Support
AdvancedMD is considered the leading EHR system that manages the entire medical practice, locations, and patient experience through flexible scheduling, simple charting, legendary billing, accurate reporting, and easy-to-use patient engagement tools. The system ensures unified workflow and cutting-edge security based on the effective EHR & EMR software with smart cloud-based clinical applications. Post-implementation support implies ongoing training for nurses to enhance their nursing documentation capacity. This step also implies the new workflow analysis to compare and evaluate the new EHR system’s benefits.
Conclusion
The process of involving a nurse leader on an implementation team for health information technology poses significant challenges and benefits that impact the successful integration of the new technology. A nursing leader must recognize that innovative projects entail redesigning the existing clinical practice and improving patient care outcomes. The new documentation system should be appropriately integrated into the medical practice to solve the current challenges and define opportunities in the documentation process of the nursing care of patients.
References
AHRQ (n. d.). Improved accuracy of coding. Agency for Healthcare Research and Quality, 09-0095, 1–2.
Digital Healthcare Research (n. d.). Workflow assessment for health IT toolkit. AHRQ. Web.
Hirsch, A. (2016). Technology management strategies. Nursing Critical Care, 11(4), 12–13.
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Jones & Bartlett Learning.
Urquhart, C., Currell, R., Grant, M. J., & Hardiker, N. R. (2018). Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Database of Systematic Reviews. Web.