NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner ​​​​​​​EHR Data Entry Protocols Purpose

Creating an electronic medical record that facilitates excellence in patient care meeting regulatory requirements, such as billing, clinical practice, necessary use, and standards of effective care, also serves as a legal record. It requires attention to detail and precise and accurate data entry. Legal, ethical, and billing compliance are no different from those governing traditional handwritten notes. However, there are fundamental differences between the EHR and paper records. EHRs have built-in support tools that can be helpful as well as problematic.

The purpose of these protocols and standards is to facilitate an organizational standardized process for data entry and documentation within the facility’s electronic medical record (EMR) based on the following:

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Electronic health records (EHRs) can improve patient safety through access to accurate and up-to-date patient information (Koppel et al., 2016). However, EHRs can also introduce new risks if not used correctly, such as errors in patient care resulting from poor data entry practices (Shim et al., 2019). To mitigate these risks and improve patient safety, we must implement strict data protocols in our healthcare organization.

Supporting evidence from the literature suggests that implementing strict data entry protocols can help reduce the risk of errors in patient care (Bates & Gawande, 2017). A systematic review and meta-analysis of the impact of EHR adoption on patient safety found that the risk of errors increased when EHRs were not used properly but that implementing strict protocols for data entry and other interventions aimed at improving EHR usability could help to reduce the risk of errors (Xu et al., 2020).

Clinical professionalism extends to the documentation of healthcare providers’ services – signing the clinical note implies that the provider takes full responsibility for the note’s content. Medical records serve to document the care provided and serve as legal documents. Entries in the EHR should be appropriate, concise, timely, relevant, and pertinent to the patient’s condition on the date the entry was made.

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Revised PICO(T) question: In healthcare organizations using EHRs (P), how does the implementation of strict protocols for data entry (I) impact the risk of errors in patient care (O) compared to no intervention (C)? Is this intervention improving patient safety (T) over three months?

It is necessary to act with the development of this policy to address the gap or problem in patient safety related to poor patient data entry practices in the organization’s EHR system. By implementing strict protocols for data entry, our healthcare organization can help reduce the risk of errors in patient care and improve patient safety. This policy has been developed based on the evidence from the literature review. It has been designed to address the identified patient safety issue in a systematic, evidence-based manner.

Population Affected by the Policy

The population affected by the policy on EHR data entry protocols includes healthcare providers and other users of the EHR, such as nurses, technicians, therapists, and other end users of the healthcare organization.

Healthcare providers, such as doctors, nurses, and other clinical staff, will be responsible for implementing the policy and ensuring compliance with the established protocols for data entry. Patients will benefit from the policy through reduced risk of errors and adverse events related to EHR use. The policy applies to all healthcare providers and patients within our organization, regardless of age, gender, race, or other demographic factors.

Definitions

Electronic health record (EHR): An electronic version of a patient’s medical history, which includes information such as medications, allergies, diagnoses, and test results. EHRs manage and share patient information within healthcare organizations and can improve patient safety by providing access to accurate and up-to-date patient information (Koppel et al., 2016).

Data entry: Entering information into an electronic system, such as an EHR. Data entry can involve transcribing information from paper records, updating information in the EHR, or entering new information into the system.

Protocol: A set of rules or guidelines that outline how a particular process or procedure should be carried out. In the context of EHR data entry, protocols may include guidelines for verifying the accuracy of entered information, procedures for double-checking critical data points, and standards for ensuring the completeness and t