How do nursing practice and data inform each other?
Nurses, who do most of the EHR documentation (in- cluding plans of care, physiological parameters, assess- ments, interventions, and progress evaluations) in hos- pitals, are critical to care integration and patient safety. Whether entered into flow sheets or as “smart phrases” or narratives, all data are important to the healthcare team’s understanding of the individual patient. Be- cause nurses regularly review individual patient data, they’re the essential communicators to providers about
Using data in nursing practice By Kimberly S. Glassman, PhD, RN, NEA-BC, FAAN
Practice Matters
46 American Nurse Today Volume 12, Number 11 AmericanNurseToday.com
any overt or subtle changes in a patient’s condition. EHRs also help nurses understand how to care for
populations of patients. To do that, information about individual patients must be extracted and compiled into flow sheet rows. Vital signs and other physio – logic measurements lend themselves nicely to flow sheet input. However, the context of the individual patient’s story—the narrative that explains why he or she sought health care and what may have led to the problem—doesn’t fit neatly into a flow sheet and
fragments the story. Nurses must partner with the vendors of EHR systems to improve this workflow so that the important narrative in- formation can be captured to im- prove health for all patients. In ambulatory care, much of the
documentation required for quality metrics (such as screening tests, to- bacco use, vaccines, and health teaching) is done by nursing staff. Some of these data are collected using a simple checkbox in the record. However, by checking yes or no about smoking, the patient can’t give any context for why he or she uses tobacco, information about multiple quitting attempts, or the as- pects of his or her life that support
or thwart the desire to quit. The opportunity for nurses to inform their documentation is essential for capturing relevant detailed patient information. And rather than serving as the recorder of the patient’s information, nurses can support simple methods for patients to cap- ture their own stories. The quality of our nursing care and documentation
informs the public and insurance companies through publicly reported measures at sites such as medicare.gov/ hospitalcompare/search.html. As the most trusted professionals, we can leverage our relationship with patients to support better engagement with EHRs to capture the important data that allows us to provide better care. Nurses have to keep the patient front and center in everything we do and our ability to advo- cate for patients can include educating and support- ing them to enter their own data into secure patient portals.