Date of Award
Summer 2023
Document Type
Final DNP Paper
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
Faculty Chair
Dr. Jolie Wildinger
Preceptor
Dr. Cathy Byers
Mentor
Dr. Beverly Sims
Abstract
Background: Electronic health records (EHRs) are commonly used within healthcare systems across the United States. Although EHRs were developed to provide safe delivery of care, poor documentation quality remains a problem. Poor HER documentation can negatively affect many patients’ health outcomes.
Purpose: The purpose of the DNP project was to determine the degree to which using a simulated electronic documentation model to train nurses in an acute care unit would decrease documentation errors and missed care and decrease missed opportunities for patient education in EHRs.
Methods: The theoretical framework was underpinned by the Donabedian model, positing that factors associated with structure, process, and outcome should be evaluated to determine the quality of a healthcare system. The convenience sample of participants (n = 15) was full-time nursing staff assigned to an acute unit in an urban hospital. All the participants completed a training session using the documentation model pre-installed in the hospital's EHR system. All the participants completed structured chart reviews involving 19 documented items before, during, and after the intervention.
Results: Using the documentation model for eight weeks helped improve the quality of the nurses' structured chart reviews by a small degree, indicated by Cramer's V = 0.00 to 0.34. The target of 100% correct responses was not reached for 3/19 (15.8%) of the documented items.
Conclusion: Using a simulated electronic record model resulted in a small to moderate significance level, reducing documentation errors. More training sessions are required before 100% documentation quality can be achieved. Training sessions would be best if the simulated documentation model is used during new employee hospital orientation before staff is released to the assigned units.
Recommended Citation
Moton-Hale, Icy, "Utilization of a Simulation Electronic Documentation Model for Healthcare Providers to Reduce Documentation Errors in a Hospital Setting" (2023). Doctor of Nursing Practice Projects. 101.
https://digitalcommons.jsu.edu/etds_nursing/101