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• W4387033173 abstract "AORN JournalVolume 118, Issue 4 p. 261-266 Safety First Documenting Perioperative Care in the Electronic Health Record Rebecca Qualey DNP, RN, Corresponding Author Rebecca Qualey DNP, RN [email protected] Search for more papers by this author Rebecca Qualey DNP, RN, Corresponding Author Rebecca Qualey DNP, RN [email protected] Search for more papers by this author First published: 26 September 2023 https://doi.org/10.1002/aorn.14010 1.0: https://aorn.us/oct23-sf Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat REFERENCES 1 American Nurses Association. ANA's Principles for Nursing Documentation. Guidance for Registered Nurses. Silver Spring, MD: ANA; 2010. Accessed June 12, 2023. http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf 2 EHR Incentive Programs 2014 CEHRT Rule: Quick Guide. Centers for Medicare & Medicaid Services. Updated August 2014. Accessed June 12, 2023. https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/cehrt2014_finalrule_quickguide.pdf 3Ball MJ, Weaver C, Abbott PA. Enabling technologies promise to revitalize the role of nursing in an era of patient safety. Int J Med Inform. 2003; 69(1): 29-38. https://doi.org/10.1016/s1386-5056(02)00063-1 4Kelley TF, Brandon DH, Docherty SL. Electronic nursing documentation as a strategy to improve quality of patient care. J Nurs Scholarsh. 2011; 43(2): 154-162. https://doi.org/10.1111/j.1547-5069.2011.01397.x 5McCarthy B, Fitzgerald S, O'Shea M, et al. Electronic nursing documentation interventions to promote or improve patient safety and quality care: a systematic review. J Nurs Manag. 2019; 27(3): 491-501. https://doi.org/10.1111/jonm.12727 6Palojoki S, Mäkelä M, Lehtonen L, Saranto K. An analysis of electronic health record–related patient safety incidents. Health Informatics J. 2017; 23(2): 134-145. https://doi.org/10.1177/1460458216631072 7Van Winkle RA, Champagne MT, Gilman-Mays M, Aucoin J. Operating room delays: meaningful use in electronic health record. Comput Inform Nurs. 2016; 34(6): 247-253. https://doi.org/10.1097/cin.0000000000000233 8Stone AB, Dangerfield S, Preiss DA, Urman RD. Costs of inaccurate anesthesia start time documentation within a health system. A A Pract. 2021; 15(2):e01404. https://doi.org/10.1213/xaa.0000000000001404 9Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the perioperative pathway. A literature review. Int J Nurs Stud. 2011; 48(8): 1024-1038. https://doi.org/10.1016/j.ijnurstu.2011.05.009 10 Nurse Professional Liability Exposure Claim Report: Minimizing Risk, Achieving Excellence. 4th ed. Fort Washington, PA: Nurses Service Organization; June 2020. Accessed June 12, 2023. https://www.nso.com/getmedia/499d682c-6855-46fb-b6b1-c12da2d7ea23/CNA_CLS_NURSE20_061120p2_CF_PROD_ONLINE_SEC.pdf 11Yontz LS, Zinn JL, Schumacher EJ. Perioperative nurses’ attitudes toward the electronic health record. J Perianesth Nurs. 2015; 30(1): 23-32. https://doi.org/10.1016/j.jopan.2014.01.007 12Kaihlanen AM, Gluschkoff K, Saranto K, Kinnunen UM, Heponiemi T. The associations of information system's support and nurses’ documentation competence with the detection of documentation-related errors: results from a nationwide survey. Health Informatics J. 2021; 27(4):14604582211054026. https://doi.org/10.1177/14604582211054026 13Frank L, Danks J. Perianesthesia nursing malpractice: reducing the risk of litigation. J Perianesth Nurs. 2019; 34(3): 463-468. https://doi.org/10.1016/j.jopan.2018.10.001 14Bjerkan J, Valderaune V, Olsen RM. Patient safety through nursing documentation: barriers identified by healthcare professionals and students. Front Comput Sci. 2021; 3:624555. https://doi.org/10.3389/fcomp.2021.624555 15Tsai CH, Eghdam A, Davoody N, Wright G, Flowerday S, Koch S. Effects of electronic health record implementation and barriers to adoption and use: a scoping review and qualitative analysis of the content. Life (Basel). 2020; 10(12): 327. https://doi.org/10.3390/life10120327 16Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag. 2013; 10(Fall): 1c. Accessed June 12, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3797550/ 17Moy AJ, Schwartz JM, Chen RJ, et al. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. J Am Med Inform Assoc. 2021; 28(5): 998-1008. https://doi.org/10.1093/jamia/ocaa325 18 Guideline for patient information management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023: 367-406. 19Mohan V, Garrison C, Gold JA. Using a new model of electronic health record training to reduce physician burnout: a plan for action. JMIR Med Inform. 2021; 9(9):e29374. https://doi.org/10.2196/29374 20Schouten AM, Flipse SM, van Nieuwenhuizen KE, Jansen FW, van der Eijk AC, van den Dobbelsteen JJ. Operating room performance optimization metrics: a systematic review. J Med Syst. 2023; 47: 19. https://doi.org/10.1007/s10916-023-01912-9 21Søndergaard SF, Lorentzen V, Sørensen EE, Frederiksen K. The documentation practice of perioperative nurses: a literature review. J Clin Nurs. 2017; 26(13-14): 1757-1769. https://doi.org/10.1111/jocn.13445 22Wright MI, Polivka B, Clark P. Exploring normalization of deviance among perioperative registered nurses in the operating room. West J Nurs Res. 2022; 44(2): 116-124. https://doi.org/10.1177/0193945921999677 23St Jacques PJ, Minear MN. Improving perioperative patient safety through the use of information technology. In: K Henriksen, JB Battles, MA Keyes, ML Grady, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Technology and Medication Safety. Vol 4. Accessed June 12, 2023. https://www.ncbi.nlm.nih.gov/books/NBK43757/ 24Wilbanks BA, Aroke EN. Using clinical simulations to train healthcare professionals to use electronic health records: a literature review. Comput Inform Nurs. 2020; 38(11): 551-561. https://doi.org/10.1097/cin.0000000000000631 25 Guideline for team communication. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023: 1153-1184. 26Lorenzi C, Duffy CC. Incorporating human factors in perioperative nursing to reduce errors. AORN J. 2021; 114(4): 380-386. https://doi.org/10.1002/aorn.13516 27 TeamSTEPPS Fundamentals Course: Module 3. Communication. Agency for Healthcare Research and Quality. March 2014. Reviewed March 2019. Accessed June 12, 2023. https://www.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html 28Usselman E, Borycki EM, Kushniruk AW. The evaluation of electronic perioperative nursing documentation using a cognitive walkthrough approach. Stud Health Technol Inform. 2015; 208: 331-336. https://doi.org/10.3233/978-1-61499-488-6-331 29Geier A, Smith D. The role of electronic documentation in ambulatory surgery centers. AORN J. 2019; 109(4): 444-450. https://doi.org/10.1002/aorn.12636 30Monfre J, Batchelor F, Skar A. Improving skin assessment documentation in the electronic health record to prevent perioperative pressure injuries. AORN J. 2022; 115(1): 53-63. https://doi.org/10.1002/aorn.13573 31 AHIMA Work Group. Integrity of the healthcare record: best practices for EHR documentation (2013 update). J AHIMA. 2013; 84(8): 58-62. Accessed June 12, 2023. https://library.ahima.org/doc?oid=300257 32Zadvinskis IM, Garvey Smith J, Yen PY. Nurses’ experience with health information technology: longitudinal qualitative study. JMIR Med Inform. 2018; 6(2):e38. https://doi.org/10.2196/medinform.8734 33Søndergaard SF, Lorentzen V, Sørensen EE, Frederiksen K. Danish perioperative nurses’ documentation: a complex, multifaceted practice connected with unit culture and nursing leadership. AORN J. 2017; 106(1): 31-41. https://doi.org/10.1016/j.aorn.2017.05.003 34Nedelcu CM, Niculiă OO, Nedelcu V, et al. Effective communication and patient safety among nurses in perioperative settings: a best practice implementation project. JBI Evid Implement. 2022; 20(suppl 1): S3-S14. https://doi.org/10.1097/XEB.0000000000000316 Volume118, Issue4Special Focus Issue: Infection PreventionOctober 2023Pages 261-266 ReferencesRelatedInformation" @default.
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