Document Smart

Document
Smart
Clinical Editor
Teri Capriotti, DO, MSN, CRNP , RN 
Clinical Professor 
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, Pennsylvania
The A-to-Z Guide to Better
Nursing Documentation
Fourth EditionExecutive Editor: Nicole Dernoski
Development Editor: Maria M. McAvey
Editorial Coordinator: Mary Woodman
Senior Production Project Manager: Alicia Jackson
Design Coordinator: Elaine Kasmer
Manufacturing Coordinator: Kathleen Brown
Marketing Manager: Linda Wetmore
Prepress Vendor: S4Carlisle Publishing Services
ourth edition
Copyright © 2020 Wolters Kluwer.
Copyright © 2011, 2007, Lippincott Williams & Wilkins; Copyright © 2001 Springhouse.
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in
any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any
information storage and retrieval system without written permission from the copyright owner, except for brief
quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as
part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To
request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA
19103, via email at [email protected], or via our website at shop.lww.com (products and services).
9 8 7 6 5 4 3 2 1
Printed in China
Library of Congress Cataloging-in-Publication Data
ISBN-13: 978-1-975120-73-3
ISBN-10: 1-975120-73-6
Cataloging-in-Publication data available on request from the Publisher.
his work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including
any warranties as to accuracy, comprehensiveness, or currency of the content of this work.
his work is no substitute for individual patient assessment based upon health care professionals’ examination of
each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions,
medication history, laboratory data and other factors unique to the patient.  The publisher does not provide med-
ical advice or guidance and this work is merely a reference tool.  Health care professionals, and not the publisher,
are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and
treatments. 
Given continuous, rapid advances in medical science and health information, independent professional verification
of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options
should be made and health care professionals should consult a variety of sources. When prescribing medication,
health care professionals are advised to consult the product information sheet (the manufacturer’s package insert)
accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify
any changes in dosage schedule or contraindications, particularly if the medication to be administered is new,
infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law,
no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of
products liability, negligence law or otherwise, or from any reference to or use by any person of this work.
shop.lww.comDEDICATION
I would like to dedicate this book to my grandsons, Ethan and Caleb Wolinsky.
TeriContributors
Jeanette M. Anderson, MSN, RN
JMA Nursing Consultant
Fort Worth, Texas
Cheryl Brady, MSN, RN, CNE
Senior Lecturer, Nursing Faculty
Kent State University
Salem, Ohio
Teri Capriotti, DO, MSN, CRNP , RN
Clinical Professor
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, Pennsylvania
Misty B. Conlan, MSN, RN, CPN
Adjunct Clinical Assistant Professor
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, Pennsylvania
Kim Cooper, RN, MSN
Nursing Department Chair
Ivy Tech Community College
Terre Haute, Indiana
Linda C. Copel, PhD, RN, PMHCNS,
BC, CNE, ANEF, NCC, FAPA
Professor
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, Pennsylvania
Carol A. Devlin, MSN, BSN, RNFA,
CNOR
PhD Student
Robert Wood Johnson Foundation Future of
Nursing Scholar, Adjunct Clinical Faculty
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, Pennsylvania
Susan B. Dickey, PhD, RN
Associate Professor
Secretary of the Temple University Faculty
Senate, 2016-18
Department of Nursing, Temple University
College of Public Health
Philadelphia, Pennsylvania
Meredith M. Greenle, PhD, RN, CRNP , CNE
Assistant Professor
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, Pennsylvania
Gwendolyn M. Hamid, BA, MSN, RN
Adjunct Clinical Instructor
Villanova University
Villanova, Pennsylvania
Melissa O’Connor, PhD, MBA, RN
Associate Professor
Distinguished Educator in Gerontological Nursing
Villanova University,
M. Louise Fitzpatrick College of Nursing
Claire M. Fagin Fellow /Patricia G. Archbold
Scholar / National Hartford Center of
Gerontological Nursing Excellence
Villanova, Pennsylvania
Alanna Owens, BSN, RN
Graduate Assistant
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, Pennsylvania
Noel C. Piano, RN, MS
Instructor/Coordinator
Lafayette School of Practical Nursing
Lafayette, Louisiana
Monica N. Ramirez, PhD, RN
Associate Professor
University of the Incarnate Word
San Antonio, TexasPREVIOUS EDITION
ADVISORY BOARD
Deborah Hutchins Allen, RN, MSN, FNP ,
APRN-BC, AOCNP
Jeanette M. Anderson, RN, MSN
Sharon Baranoski, MSN, RN, CWCN, APN-
CCNS, FAAN
Valerie A. Barron, RN, BC, MS, CCRN
Marissa U. Camanga-Reyes, RN, MN, CNS
Kim Cooper, RN, MSN
Kim R. Davis, RN, MSN
Laurie Donaghy, ADN, RN, CEN
Christine Greenidge, APRN, BC, MSN, DHA
Kathleen M. Hill, RN, MSN, CCNS-CSC
Julia Anne Isen, RN, MS, FNP-C
Susan M. Kilroy, RN, MS
Linda Laskowski-Jones, RN, APRN, BC, MS,
CCRN, CEN
Cyndie Miculan, RN, MSN, ONC, CE-BC
Nicolette C. Mininni, RN, MED, CCRN
Monica Narvaez Ramirez, RN, MSN
Lauren R. Roach, LPN, HCSD
Amanda Stefancyk, RN, MSN, MBA
Allison Terry, RN, MSN, PhD
Genevieve M. Thul, RN, BSN
Suzanne P . Weaver, RN, BSN, RHIT, CPHQ
PREVIOUS EDITION
CONTRIBUTORS
Jeanette M. Anderson, RN, MSN
Marissa U. Camanga-Reyes, RN, MN, CNS
Kim Cooper, RN, MSN
Kim R. Davis, RN, MSN
Laurie Donaghy, ADN, RN, CEN
Julia Anne Isen, RN, MS, FNP-C
Susan M. Kilroy, RN, MS
Cyndie Miculan, RN, MSN, ONC, CE-BC
Monica Narvaez Ramirez, RN, MSN
Lauren R. Roach, LPN, HCSD
Allison Terry, RN, MSN, PhD
Genevieve M. Thul, RN, BSN
Suzanne P . Weaver, RN, BSN, RHIT, CPHQForeword
In all areas of health care practice, complete and timely documentation
of a patient’s care remains a key factor in achieving positive treatment
outcomes. As the number of people and disciplines involved in patient
care expands, comprehensive and accurate communication among
health care providers is essential. Time to document is becoming a
scarce commodity. With increases in workload, the nurse needs to know
how to be concise in charting while making sure crucial information is
entered into the patient’s record.
Document Smart: The A-to-Z Guide to Better Nursing Documentation is
an easy-to-use reference covering all aspects of documentation about
patient care, from the assessment of patient data to the formulation of
effective patient goals and optimal nursing interventions, evaluation of
treatment, and patient teaching and education.
There is specific content regarding the Health Insurance Portability
and Accountability Act (HIPAA) regulations, which are essential to fol-
low when documenting and communicating about patient care.
The text also contains information about charting in the electronic
health record (EHR). Electronic health records are used across most
health care settings at this time; however, individual institutions use dif-
ferent EHR software programs. These different EHR software programs
pose a challenge for the presentation of electronic charting in this
book. It is up to the nurse and other health care providers to obtain
training in their individual facility to understand how to chart within
the institution’s EHR. This book offers examples of essential informa-
tion to document; however, it is not able to demonstrate how to use
specific forms of EHRs.
Document Smart has synthesized information from many sources to
recommend how to deliver safe and high-quality nursing care. Recom-
mendations for safe nursing interventions from The Joint Commission
are included. Measures needed for safe administration of medications
from the Institute of Safe Medication Practices (ISMP) are included.
The Quality and Safety Education (QSEN) Institute competencies have
also been used to teach how to perform safe and high-quality nursing
documentation and interventions.A new list of current nursing diagnoses from NANDA International
(NANDA-I) is included in this book. Health care institutions vary in
their recommendations for using the approved NANDA-I nursing diag-
noses in charting about patient care. It is up to the nurse to review indi-
vidual facility policies regarding the use of NANDA-I terminology.
No matter where the nurse practices, from hospital to outpatient
to home health care settings, the nurse will find that Document Smart is
a valuable resource for performing safe and high-quality patient care
documentation.
Teri Capriotti, DO, MSN, CRNP , RN
Clinical Professor
Villanova University
M. Louise Fitzpatrick College of Nursing
Villanova, PAContents
INTRODUCTION
Computerized and Electronic Health Records xiii
Safe Medication Administration and Use of Barcodes on Medications xix
DOCUMENTATION (in alphabetical order)
A
Abuse, Suspected 1
Activities of Daily Living 4
Advance Directive 9
Advice to Patient by Telephone 11
Against Medical Advice, Discharge 13
Against Medical Advice, Out of Bed 15
Alcohol Found at Bedside 16
Allergy Testing 18
Anaphylaxis 19
Arrhythmias 20
Arterial Blood Sampling 21
Arterial Line Insertion 22
Arterial Line Removal 23
Arterial Occlusion, Acute 24
Arterial Pressure Monitoring 26
Arthroplasty Care 27
Aspiration, Foreign Body 28
Aspiration, Tube Feeding 29
Assessment, Initial 31
Asthma 31
B
Bladder Irrigation, Continuous 37
Blank Spaces in Chart or Flow Sheet 39
Blood Transfusion 40
Blood Transfusion Reaction 43
Bone Marrow Aspiration and Biopsy 47
Brain Death 49
Burns, Assessment and Nursing Care 52
C
Cardiac Monitoring (Telemetry) 59
Cardiac Tamponade 59
Cardiopulmonary Arrest and
Resuscitation 61
Cardioversion, Synchronized 63
Caregiver Strain 64
Care Plan, Traditional 65
Cast Care 67
Central Venous Access Device Insertion 68
Central Venous Access Device Occlusion 69
Central Venous Access Device Removal 70
Central Venous Access Device Site Care 70
Central Venous Pressure Monitoring 71
Chest Pain 72
Chest Tube Care 73
Chest Tube Insertion 74
Chest Tube Removal 75
Chest Tube Removal by Patient 76
Clinical Pathway 78
Cold Therapy Application 78
Confusion 81
Continuous Renal Replacement Therapy 82
Correction to Documentation 83
Critical Test Values, Reporting 84
Cultural Needs Identification 85
D
Death of a Patient 91
Dehydration, Acute 92
Dementia 93
Diabetic Ketoacidosis 94
Discharge Instructions 96
Do-Not-Resuscitate Order 98
Computerized Physician Order Entry
(Formerly Called Doctor’s Orders) 99
Health Care Provider’s Orders, Telephone 101
Health Care Provider’s Orders, Verbal 101
Drug Administration 102
Drug Administration, Adverse Effects of 107
Drug Administration, One-Time Dose 109
Drug Administration, Opioid 110
Drug Administration, Stat Order 110Drug Administration, Withholding
Ordered Drug 111
Drugs, Illegal 112
Drugs, Inappropriate Use of 113
Drugs, Patient Hiding 114
Drugs, Patient Refusal to Take 115
Dyspnea 116
E
Elopement from a Health Care Facility 121
Emergency Treatment, Patient
Refusal of 121
End-of-Life Care 123
Endotracheal Extubation 124
Endotracheal Intubation 125
Endotracheal Tube, Patient Removal of 126
End-Tidal Carbon Dioxide Monitoring 127
Enema Administration 128
Epidural Analgesia 129
Epidural Hematoma 130
Esophageal Tube Insertion (Sengstaken–
Blakemore Tube) 131
Esophageal Tube Removal 132
Experimental Procedures 133
F
Failure to Provide Information 137
Falls, Patient 138
Falls, Precautions 140
Falls, Visitor or Other 144
Firearms at Bedside 145
Firearms in the Home 146
Firearms on Family Member or Visitor 147
G
Gastric Lavage 149
Gastrointestinal Hemorrhage 150
H
Health Insurance Portability and
Accountability Act 153
Hearing Impairment 155
Heart Failure, Daily Assessment 156
Heat Therapy 157
Hemodynamic Monitoring 158
Home Care, Home Care Aide Needs 160
Home Care, Initial Assessment 160
Home Care, Interdisciplinary
Communication in 163
Home Care, Patient-Teaching
Certification in 165
Home Care Discharge Summary 170
Home Care Progress Notes 172
Home Care Recertification 174
Home Care Referral 176
Home Care Telephone Orders 178
Hyperglycemia 180
Hyperosmolar Hyperglycemic
Nonketotic Syndrome 181
Hypertensive Crisis 182
Hyperthermia-Hypothermia Blanket 184
Hypoglycemia 185
Hypotension 187
Hypovolemia 188
Hypoxemia 190
IJK
Illegal Alteration of a
Medical Record 193
Implanted Port, Accessing 194
Implanted Port, Care of 196
Implanted Port, Withdrawing
Access 197
Inappropriate Comment in the
Medical Record 198
Incident Report 200
Increased Intracranial Pressure 203
Infection Control 204
Informed Consent, Inability to Give 205
Informed Consent in Emergency
Situation 206
Informed Consent, Lack of
Understanding of 208
Informed Consent When Patient
is a Minor 209
Intake and Output 210
Intestinal Obstruction 212
Intra-Aortic Balloon
Counterpulsation Care 214
Intra-Aortic Balloon Insertion 215
Intra-Aortic Balloon Removal 217
Intracerebral Hemorrhage 218
Intracranial Pressure Monitoring 219
Intravenous Catheter Complication:
Cannula Dislodgment 221
Intravenous Catheter Complication:
Phlebitis 221
Intravenous Catheter Insertion 222
Intravenous Catheter Removal 223
Intravenous Site Care 224
Intravenous Site Change 225
Intravenous Site Infiltration 226L
Language Difficulties 231
Last Will and Testament, Patient
Request for Witness of 233
Late-Documentation Entry 235
Latex Hypersensitivity 236
Level of Consciousness, Changes in 237
Lumbar Puncture 239
M
Mechanical Ventilation 243
Medical Advice, Patient or
Family Request for 244
Medication Error 246
Medications, Reconciling 249
Misuse of Equipment 251
Mixed Venous Oxygen Saturation
Monitoring 252
Moderate Sedation 252
Multiple Trauma 254
Myocardial Infarction, Acute 256
N
Nasogastric Tube Care 261
Nasogastric Tube Insertion 262
Nasogastric Tube Removal 263
Newborn Identification 263
Patient Nonadherence to
Recommended Medical Care 265
O
Organ Donation 267
Ostomy Care 268
Overdose, Drug 269
Oxygen Administration 271
P
Pacemaker, Care of Permanent 273
Pacemaker, Care of Transcutaneous 274
Pacemaker, Care of Transvenous 275
Pacemaker, Initiation of
Transcutaneous 277
Pacemaker, Insertion of Permanent 278
Pacemaker, Insertion of Transvenous 279
Pacemaker Malfunction 280
Pain Management 282
Paracentesis 284
Parenteral Nutrition Administration,
Lipids 286
Parenteral Nutrition Administration,
Total 286
Patient Requesting Access to
Medical Records 289
Patient Self-Documentation of Care 289
Patient Self–Glucose Testing 291
Patient Teaching 293
Patient Teaching, Patient’s Refusal of 298
Patient Threat of Self-Harm 299
Patient Threat to Harm Another 300
Patient Transfer to Long-Term
Care Facility 302
Patient Transfer to Specialty Unit 306
Patient’s Belongings, at Admission 307
Peripherally Inserted Central
Catheter Site Care 307
Peritoneal Dialysis 308
Peritoneal Dialysis, Continuous
Ambulatory 310
Peritoneal Lavage (Diagnostic
Peritoneal Aspiration [DPA]) 311
Peritonitis 312
Pneumonia 313
Pneumothorax 314
Poisoning 316
Postoperative Care 317
Preoperative Care 319
Pressure Ulcer (Pressure Injury)
Assessment 321
Pressure Ulcer (Pressure Injury) Care 328
Psychosis, Acute 329
Pulmonary Edema 331
Pulmonary Embolism 332
Pulse Oximetry 334
Q
Quality of Care, Family Questions
About 339
R
Rape-Trauma Syndrome 341
Refusal of Treatment 344
Acute Kidney Injury 345
Reports to Health Care Provider 347
Respiratory Arrest 348
Respiratory Distress 349
Restraints 351
S
SBAR 355
Seclusion 357
Seizure Management 359
Shock 361Skin Care 364
Skin Graft Care 365
Smoking 366
SOAP 368
Spinal Cord Injury 369
Splint Application 371
Status Asthmaticus 372
Status Epilepticus 374
Stroke 375
Surgical Amputation Care 379
Subdural Hematoma 380
Substance Abuse by Colleague,
Suspicion of 382
Substance Withdrawal 383
Suicidal Intent 384
Suicide Precautions 386
Suicide Prevention Contract 387
Surgical Incision Care 390
Surgical Site Identification 391
Suture Removal 394
T
ermination of Life Support 397
Thoracentesis 399
Thrombolytic Therapy 400
racheostomy Care 401
racheostomy Occlusion 403
racheostomy Suctioning 404
racheostomy Tube Replacement 404
racheotomy 406
raction Care, Skeletal 408
raction Care, Skin 409
ranscutaneous Electrical Nerve
Stimulation 410
ransfusion Reaction, Delayed 411
ransient Ischemic Attack 412
ube Feeding (Enteral Feeding) 413
uberculosis 415
U
Unresponsiveness by Patient 419
Urinary Catheter Insertion,
Indwelling 420
V
Vagal Maneuvers 423
Ventricular Assist Device 425
Violent Patient 426
Vision Impairment 428
Vital Signs, Frequent 429
WXY
Walker Use 433
Wound Assessment 434
Wound Care 436
Wound Dehiscence 438
Wound Evisceration 439
Z
Z-Track Injection 441
APPENDICES
Standardized Systems 443
The Joint Commission
Abbreviations to Avoid 447
Institute for Safe Medication
Practices (ISMP) Drug Sound-Alike/
Look-Alike Names 449
Common Charting Mistakes to Avoid 455
Charting Checkup: When the Nurse
is on Trial—How to Protect Oneself 457
The NANDA International Nursing
Diagnoses 459
INDEX 469Computerized and Electronic
Health Records
THE ELECTRONIC HEALTH RECORD
Throughout this book there will be references to the electronic health
record (EHR), sometimes called the electronic medical record (EMR)
or computerized medical records. Health information technology
(HIT) has emerged as a key tool for making necessary improvements
in health care quality and cost. EHRs are a major component of HIT
that have been advocated to enhance patient safety and efficiency of
patient care. As a part of the American Recovery and Reinvestment Act
of 2009, all public and private health care providers were required to
adopt and demonstrate the use of EMRs by January 1, 2014 in order to
maintain their existing Medicaid and Medicare reimbursement levels.
Since that date, the use of electronic medical and health records has
spread worldwide and shown its many benefits to health organizations
everywhere. Given the current mandate requiring the use of EHRs, au-
tomated nursing documentation will affect the work of every nurse.
EHRs are real-time, patient-centered records. They make informa-
tion available instantly, at the time of patient care. EHRs bring patient
information from different sources together into one digital record. An
EHR can bring information from current and past health care provid-
ers, emergency visits, school and workplace clinics, pharmacies, labora-
tories, and medical imaging facilities.
In 2003, the Institute of Medicine identified basic health care de -
livery functions that EHR systems should be capable of performing
in order to promote greater safety, quality, and efficiency in health
care delivery.
• contain information about a patient’s medical history, diagnoses,
medications, immunization dates, allergies, images, consultations,
and lab and procedure results
• offer access to evidence-based tools that providers can use in making
decisions about a patient’s care
• streamline providers’ workflow to provide seamless interprofessional
communication• increase organization and accuracy of patient information
• support institutional administrative processes
• assist providers provide patient education and report population
health data; to accelerate the use of HIT, in 2009, Congress passed
and President Obama signed into law the Health Information Tech-
nology for Economic and Clinical Health (HITECH) Act, which is
part of the American Recovery and Reinvestment Act
HITECH makes incentive payments available to hospitals and health
care professionals who adopt EHRs certified by the Office of the Na -
tional Coordinator for Health Information Technology and use them
effectively in the course of care. EHRs have been associated with re-
ductions in medication administration errors and improved nursing
documentation; nursing communication and workflow are enhanced
as well. As of May 2015, more than $20.5 billion in Medicare EHR in-
centive program payments and $9.7 billion in Medicaid EHR incentive
program payments have been made.
There are many different EHR software systems, and different types
of health care settings use individualized designs that suit the needs of
their providers and patient population.
The process of nursing documentation within EHRs is primarily data
entry into discrete fields in rows and columns similar to a spreadsheet.
Flow sheets are commonly used by nurses within the EHR. Documentation
of nursing care in the EHR occurs in real time at the point of care. Pa-
tient physiologic monitors, lab results, and imaging studies are commonly
linked to EHR documentation systems. This reduces the need of record-
ing some patient care data as was done in the past in handwritten nurse
notes. However, patient physiologic monitors are rarely fully integrated
with the EHR, requiring nurses to manually enter some data into the
EHR. Many EHR systems are still evolving to capture all the details of nurs-
ing care. It is recognized that standardized terminologies used in EHRs
may not contain all concepts reflecting nursing care. Therefore, some
handwritten nursing notes may still be a needed component in EHRs.
POSITIVE AND NEGATIVE EFFECTS OF EHR
ON PATIENT CARE
A literature review by Waneka and Spetz (2010) on the impact of EHR
systems on nursing care was found to be generally positive. Overall,
EHRs are associated with reductions in medication administration errors and time spent on documentation, as well as improved quality
of nursing documentation. Nurse communication and workflow seem
to be positively influenced by technology as studies have identified
nurse satisfaction with improved integration of technology systems into
workflow processes, such as documentation, medication, and patient
discharges and transfers.
One of the greatest disadvantages of EHRs is the difficulty in main -
taining privacy and addressing security risks. More specifically, viable
EHR systems must constantly work to prevent unauthorized patient
information access that may originate from internal and external path-
ways. Internal threats to private patient information may result from
such things as poor password management, irresponsible employees,
and transparent physical security measures. External threats include un-
authorized access to protected health information by hackers and theft
of electronic devices containing health information (Amatayabul, 2011).
In a research survey, 7,000 nurses responded negatively to question-
ing about the nurses’ experience with documentation requirements in
the EHR (Stokowski, 2013). Some of the nurse’s comments in the study
included:
• I feel like a data entry clerk.
• We’re “nursing” the medical record rather than the patient.
• I need a stenographer to follow me around during my work and re-
cord everything I see, discover, think, evaluate, and do.
• I “nurse” a computer instead of a patient, and it’s made very clear
that the computer input is more important than the patient.
• I rest easy at night knowing I didn’t sacrifice bedside care to click
boxes on a screen.
• In reality, we don’t need to do anything at all for the patient, as long
as we document that we did.
• I never thought I would see the day when a machine would need to
be cared for more than my patient.
To remedy any problems that are discovered in the course of electronic
documentation, nurses are encouraged to keep a list of EHR functions
that they believe need to be improved. This list should be shared with
hospital leadership and the information technology (IT) team respon-
sible for upgrading, revising, and maintaining the system (Burns, Gas-
sert, & Cipriano, 2008).
Researchers in patient safety assert that problems can occur when
clinical staff automatically trust that EHR systems are working properly. Health care providers need to be constantly vigilant regarding their
documentation in the EHR. Data mistakes via copy–paste transactions
often occur. Use of templates with automatic data population can be in-
accurate. Recurring errors should trigger investigation by health IT spe-
cialists within the organization. The EHR is a tool that is still evolving.
Mistakes and errors provide valuable lessons that both clinicians and
health IT developers could use to reduce the risk of harm in the future
(Rouleau et al., 2017).
BENEFITS OF EHR FOR PATIENTS
EHRs affect not only providers and health care agencies, but also
patients. EHRs can enhance the patients’ ability to follow their own
health care plans. EHRs facilitate a patient’s ability to review and
re-review information contained in the record, to absorb medical in-
formation at their own pace, to question what is not understandable,
to provide additional information that has not been solicited, and to
report additional information. A recent study was conducted by Reed
and colleagues to determine whether utilization of an EHR system
could positively impact health outcomes among over 169,000 patients
with diabetes. Study participants who had access to their health care
information demonstrated significant improvements in their hemoglo -
bin A1C values, lipid levels, and frequency of monitoring, particularly
among those whose diabetes was not previously well controlled (Reed
et al. 2012).
WHEN USING EHRS (ALSO CALLED COMPUTERIZED
HEALTH RECORDS), THE NURSE NEEDS TO BE SURE TO
MAINTAIN CONFIDENTIALITY
• Never share
Never give your password or computer code to anyone—including
another nurse in the unit, a nurse serving temporarily in the unit, or
a health care provider. Your health care facility can issue a short-term
password that allows infrequent users to access certain records.
• Log off
After you log into a computer terminal, don’t leave the terminal un-
attended. Although some computer systems have a timing device that
automatically shuts off the user after an idle period, you should get into
the habit of logging off the system before leaving the terminal.• Don’t display
Don’t leave information about a patient displayed on a monitor where
others can see it. Also, don’t leave print versions or excerpts of the
medical record unattended.
• Never use the organization or facility computer for personal use.
• Never document another health care provider’s notes.
REFERENCES
Amatayabul, M. K. (2011). Electronic health records: A practical guide for professionals & organi-
zations (5th ed.). Chicago, IL: American Health Information Association.
Burns, L. B., Gassert, A. C., & Cipriano, P. F. (2008). Smart technology, enduring solu-
tions. Journal of Healthcare Information Management, 22(4), 24–30.
Reed, M., Huang, J., Graetz, I., Brand R., Hsu, J., Fireman, B., & Jaffe, M. (2012). Outpa-
tient electronic health records and the clinical care and outcomes of patients with
diabetes mellitus. Annals of Internal Medicine, 157(7), 482–489.
Rouleau, G., Gagnon, M. P., Cote, J., Payne-Gagnon, J., Hudson, E., & Dubois, C. H.
(2017). Impact of information and communication technologies on nursing care:
Results of an overview of systematic reviews. Journal of Medical Internet Research, 19(4),
e122.
Stokowski, L. A. (2013). Electronic nursing documentation: charting new territory.
Medscape.
Waneka, R., & Spetz, J. (2010). Hospital information technology systems’ impact on
nurses and nursing care. Journal of Nursing Administration, 40(12), 509–514.SAFE MEDICATION
ADMINISTRATION AND
USE OF BAR CODES ON
MEDICATIONS
Nurses must follow a series of steps for safe and accurate medication
administration. Within the curriculum of nursing education, medica-
tion administration is taught in a step-by-step manner. The “rights of
medication administration” are a commonly taught system for safe and
accurate administration of medication. There are a few different sets
of “rights of medication” administration in the literature: 5, 9, 10, and
12 rights of medication administration (Bourbonnais & Caswell, 2014;
Chu, 2016; Elliot & Liu, 2010; Jones & Trieber, 2018).
The following are the 12 rights of medication administration:
1. right patient
2. right medication
3. right dosage of medication
4. right route of medication
5. right time for medication
6. right assessment of patient prior to administration of medication
7. right medication preparation
8. right expiration date on medication
9. right of patient to refuse medication
10. right of patient to understand reason for medication
11. right documentation of medication administration
12. right evaluation of medication effect
The following rules to follow are of particular importance:
• Check the patient identification bracelet.
• Have the patient state his/her name.
• Address the patient by name prior to drug administration.
• Always double-check medication order if patient questions the
medication.
• Check the drug label three times before administration.
With each step in the process there is potential for error, because of
interruptions, complexity of tasks, and not following the “rights” of medication administration. Medication errors in hospitals can lead to
patient harm. It is estimated that one in three hospital adverse events
are related to a medication. This can be a medication error, adverse
effect, overdose, or allergic reaction (Office of Disease Prevention and
Health Promotion, 2018). In the past, researchers found that medica-
tion errors were responsible for approximately 7,000 deaths each year,
with a national cost annually of $2 billion (Institute of Medicine, 1999).
Studies also estimated that there were approximately 6.5 adverse events
related to medication use per 100 inpatient admissions. The majority of
these adverse events were preventable (Bates et al., 1995).
Prior to institution of bar code medication administration (BCMA),
studies found that the majority of medication errors that affected a hos-
pitalized patient occurred when the medication was incorrectly admin-
istered at the patient’s bedside (Bates et al., 1995).
A study by Wideman and colleagues (2010) found that the incidence
of adverse drug events was highest in the medical ICU, followed by the
general medical units and the general surgical units. More than one-
fourth of these events were due to preventable errors.
To help prevent such errors, technology has been developed to verify
medications with an electronic medication administration system using
bar codes. Bar code verification technology has been used as a strategy
for reducing medication errors (Macias, Bernabeu-Andreu, Arribas,
Navarro, & Baldominos, 2018; Poon, et al., 2010; Wideman, Whittler, &
Anderson, 2010). It does so by guiding users through the appropriate
medication verification process, recording medication administration
data correctly, and alerting the users to potential errors, all at the pa-
tient’s bedside (DeYoung, VanderKooi, & Barletta, 2009). Paoletti and
colleagues (2007) found that the BCMA system reduced medication
errors by 54% and significantly improved pharmacy–nursing commu -
nication interactions. DeYoung et al. (2009) found that BCMA reduced
medication errors in the adult ICU by 56%. Many investigators have
found that the bar code system helps to ensure that the “rights of medi-
cation administration” in nursing are implemented (Agrawal & Glasser,
2009; Macias et al., 2018; Wideman et al., 2010).
Nurses retrieve medications from an automatic medication dispens-
ing system in a medication room. Nurses then commonly use a mobile
workstation that is brought to the patient’s bedside. At this workstation
at the patient’s bedside, the documentation of medication administra-
tion occurs at the point of care in real time (Bowers et al., 2015).When a nurse scans a patient’s wristband using a handheld scanning
device (see Figures 1 to 3), the electronic record opens to the patient’s
medication administration record (MAR). The BCMA software guides
the nurse in reviewing the MAR and determining which medications
are due for patient administration. After selecting and preparing
the medications for administration, the nurse scans the bar code on
the unit dose medication package. If the scanned medication matches
FIG 1: Barcode scanner and medication barcode.FIG 2: Nurse using barcode scanner and electronic medication administration
record.
FIG 3: Barcode medication administration workflow from health care provider
entry of medication order to pharmacy medication packaging to med cart on
unit that contains medication to nurse who dispenses medication and uses
barcode scanner on the patient to electronic medication administration record.the medication on the profile, including dose, route, and time, the
nurse completes the verification process and administers the medica -
tion. However, if the drug is not on the patient’s medication profile,
the dose is too high or too low, the dosage form is incorrect for the in-
tended route of administration, or the administration time is too early
or too late, an alert is generated to warn the nurse of a potential medi-
cation error (Bowers et al., 2015).
Despite increasing usage of BCMA, evidence of the effectiveness of
the bar code technology has been limited and mixed. Several studies
have highlighted certain unintended consequences of its implemen-
tation, with some users either bypassing this technology or relying on
the technology without using nursing judgment, increasing the risk of
errors (Rack, Dudjak, & Wolf, 2012).According to a study by Bowers
et al. (2015), medication safety is paramount to patient care. The data
retrieved during this study indicate that BCMA has the potential to be
a valuable tool when used at the bedside to ensure that the “rights of
medication administration” are conducted. Medication information dis-
played on the mobile workstation at the bedside ensures that the most
current orders are being implemented. Technology does not, however,
replace the keen observation of the nurse when determining the ad-
visability of any medication or treatment. This technology is a tool that
when used appropriately can enhance the ability to provide safe care
(McNulty, Donnelly, & Lorio, 2009).
REFERENCES
Agrawal, A., & Glasser, A. R. (2009). Barcode medication administration implementation
in an acute care hospital and lessons learned. Journal of Healthcare Information Man-
agement, 23(4), 24–29.
Bates, D. W., Cullen, D. J., Laird, N., Petersen, L. A., Small, S. D., Servi, D., . . . Hallisey, R.
(1995). Incidence of adverse drug events and potential adverse drug events: Implica-
tions for prevention. JAMA, 274, 29–34.
Bourbonnais, F. F., & Caswell, W. (2014). Teaching successful medication administration
today: More than just knowing your ‘rights’. Nurse Education in Practice, 14(4),
391–395.
Bowers, A. M., Goda, K., Bene, V., Sibila, K., Piccin, R., Golla, S., . . . Zell, K. (2015).
Impact of bar code medication administration. Computers, Informatics, & Nursing,
33(11), 502–508.
Chu, R. Z. (2016). Simple steps to reduce medication errors. Nursing, 46(8), 63–65.
DeYoung, J. L., VanderKooi, M. E., & Barletta, J. F. (2009). Effect of bar-code-assisted
medication administration on medication error rates in an adult medical intensive
care unit. American Journal of Health System Pharmacy, 66(12), 1110–1115.Elliott, M., & Liu, Y. (2010). The nine rights of medication administration: An overview.
British Journal of Nursing, 19(5), 300–305.
Institute of Medicine. (1999). To err is human: Building a safer health system. Washington,
DC: National Academy Press.
Jones, J. H., & Treiber, L. A. (2018). Nurses’ rights of medication administration: Includ-
ing authority with accountability and responsibility. Nursing Forum, 53(3), 299–303.
Macias, M., Bernabeu-Andreu, F. A., Arribas, I., Navarro, F., & Baldominos, G. (2018).
Impact of a barcode medication administration system on patient safety. Oncology
Nursing Forum, 45(1), E1–E13.
McNulty, J., Donnelly, E., & Iorio, K. (2009). Methodologies for sustaining Barcode med-
ication administration compliance. Journal of Healthcare Information Management,
23(4), 30–33.
Office of Disease Prevention and Health Promotion. (2018, October 11). Adverse drug
events. Retrieved from https://health.gov/hcq/ade.aspPaoletti, R. D., Suess, T. M.,
Lesko, M. G., Feroli, A. A., Kennel, J. A., Mahler, J. M., & Sauders, T. (2007). Using
bar-code technology and medication observation methodology for safer medication
administration. American Journal of Health-System Pharmacy, 64(5), 536–543.
Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., . . .
Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication ad-
ministration. New England Journal of Medicine, 362(18), 1698–1707.
Rack, L. L., Dudjak, L. A., & Wolf, G. A. (2012). Study of nurse workarounds in a hospital
using barcode medication administration system. Journal of Nursing Care Quality,
27(3), 232–239.
Wideman, M. V., Whittler, M. E., & Anderson, T. M. (2010). Barcode medication admin-
istration: Lessons learned from an intensive care unit implementation. Advances in
Patient Safety, 3, 437–451.