NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

To ensure that the guidelines are being followed and that the policy has the intended impact on patient safety, Compliance will be monitored with the guidelines regularly. This may involve conducting regular audits of data entry practices, reviewing regulatory regularly racy and completeness, and identifying and addressing any issues that may arise.

To determine whether the policy is effective in improving patient safety and reducing the risk of errors in patient care, we will assess the effectiveness of the policy regularly. This may involve collecting data

on adverse events related to EHR use, measuring patient satisfaction with the quality of care,

and reviewing the EHR for accuracy and completeness. Based on the results of these assessments, we may make modifications to the policy as needed to optimize its effectiveness.

Electronic Documentation Tools

Data entry and review of the data entered will be completed using the team block data entry method, where after entry of selected data into the patient chart (demographics, insurance information, provider, and care team) will be reviewed by a peer who, in turn, is responsible for validating information has been entered correctly, before compiling this section of the patient medical records.

This two-step process will authenticate that the data entered is correct and concise.

It has been determined that several functions, though capable with this EHR system, have yet to be advocated (such as copy and paste and unauthorized templates).

Copy and Paste should be avoided as much as possible.

Copying another provider’s previous note should be avoided. Copying and forwarding lists (problem lists, allergies, medication records, health maintenance, and immunization records) are acceptable. Be aware that this information should be reviewed and updated by the provider. Lab results should be imported from the laboratory data integrated with the EHR.

Timeliness: 

Timely completion of medical record entry is required; visit notes should be completed within 24 hours of the patient visit. Notes should be finalized and signed within 24 hours of the service date. The EHR system has a clinical log report that the clinician can review, which will help determine if all notes are completed and signed. (This can aid in compliance for the provider and the data entry person; each section that still needs to be completed will be highlighted and assigned to the employee). The clinical team leader/supervisor will run weekly reports and notify employees and providers of any deficiencies in this area.

Supervision: 

Providers are required to author their notes except for using an organization-approved scribe. Employees must not share passwords for logging in to the EHR. Providers may not edit or change the content of another provider’s note. Once the note is finalized, an addendum should be used to document additional information or further clarification of services.

References

Agency for Healthcare Research and Quality. (2018). Patient satisfaction surveys. [Website link]. http://www.ahrq.gov/patient-safety/settings/primary-care/resources/quality-improvement/patient-satisfaction-survey/index.html

Antonacci, G., Lennox, L., Barlow, J., Evans, L., & Reed, J. (2021). Process Mapping in Healthcare: A Systematic Review. BMC Health Services Research, 21(1), 342. https://doi.org/10.1186/s12913-021-06254-1

Ash, S. J., Corby, S., Mohan, V., Solberg, N., Becton, J., Bergstrom, R., Orwoll, B., Hoekstra, C., & Gold, J. A. (2020). Safe use of the EHR by medical scribes: A qualitative study. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocaa199

Bani, I. W., Akour, I., Ibrahim, A., Almarzouqi, A., Abbas, S., Hisham, F., & Griffiths, J. (2020). Privacy, confidentiality, security, and patient safety concerns about electronic health records. International Nursing Review, 67(2), 218–230. https://doi.org/10.111/inr.12585

Bates, D. W., & Gawande, A. A. (2017). Patient safety and electronic health records. New England Journal of Medicine, 376(3), 193–195.

Bersani, K., Fuller, T. E., Garabedian, P., Espares, J., Mlaver, E., Businger, A., Chang, F., Boxer, R. B., Schnock, K. O., Rozenblum, R., Dykes, P. C., Dalal, A. K., Benneyan, J. C., , L. S., Lehmann, Gershanik, E. F., Bates, D. W., & Schnipper, J. L. (2020). Use, Perce