| Description |
Nursing documentation is crucial in several ways for delivering safe patient care and is used to support multiple components of care delivery. First, it is important for communicating patients' conditions and nursing care plans among healthcare providers, the patient's family, and other parties. Nursing documentation includes information that explains a patient's status or services they received (College and Association of registered nurses of Alberta Provincial, 2006). Second, it is considered as evidence of the care that nurses provide to their patients. According to the American Nursing Association, nursing documentation should be accurate, unambiguous, and available because it is an essential component of quality, safety, and evidence-based nursing practice (American Nurses Association, 2010). Third, nursing documents reflect the nursing process: assessment, diagnosis, planning, implementation, and evaluation in the nursing care that is delivered to patients. Despite the value of documentation listed above, documentation is challenging and creates problems. A study showed that document completion is time-consuming. In fact, nurses spent about 25% of their time reviewing and charting documentation on both paper and in the electronic health record (EHR) (Yen et al., 2018). In addition, some clinical content in documents is redundant, irrelevant, and not standardized, which increases problem severity. Researchers reported that 42.9% of providers identified one of the causes of burnout as redundant documentation in the EHR (Raney et al., 2020). Documentation addresses the task of inputting data into an EHR. There are many options for getting data into an EHR, but flowsheets are a special kind of documentation tool used by nurses. A flowsheet is a checklist for data points such as nursing care tasks, patient assessments, and observations (Winden et al., 2018). While flowsheets are commonly used, it has advantages and disadvantages. Flowsheet documentation can improve patient care, time management, work efficiency, and continuity of care (Collins et al., 2018). However, flowsheet documentation may have disadvantages, including redundancies and over-documentation. At the University of Utah Healthcare (UHealth), flowsheets are commonly used and were implemented in 2014, but have not been updated since then. The infant flowsheet contains essential patient information such as vital signs, hygiene status, and patient safety information. At the Neonatal Intensive Care Unit (NICU), Intermediate Care Nursery (ICN), and Nursery unit, nurses use infant flowsheets to frequently document their patient's clinical status. Since these flowsheets were initially introduced in 2014, numerous enhancement opportunities have been identified. Hence, the infant flowsheet should be improved for easier and more effective use and capture higher quality nursing documentation. Some clinical content in the flowsheet is not standardized, is redundant, and contains irrelevant information. These issues cause time-consuming documentation, are not user-friendly, and create workflow interruption. This has created problems that now need to be addressed.According to a conceptual model of the system development life cycle (SDLC), the maintenance phase is the post-implementation task that will keep the system operational, update it to meet quality standards, and enhance it throughout its life (Conger, 2011). The infant flowsheet has not been evaluated since it was implemented. With this research opportunity, the infant flowsheet's clinical data will be standardized, and usability will be considered and addressed.To address the problem of non-standard, redundant, and irrelevant information in the flowsheet, the study's goals are to improve the infant flowsheet quality, usability, and efficiency of documentation. The project's specific objectives are (a) to define the data and user requirements for a single infant daily cares flowsheet to be used by the NICU, ICN and nursery instead of separate flowsheets, (b) to describe the change before and after re-designing the flowsheet, and (c) to assess the usability of the proposed infant flowsheet and make enhancements as needed for the final re-design. |
