Background and Significance The 2014 Mandate within the Affordable Care Act states that medical records need to be in an electronic format by this year. The purpose of our initiative was to standardize language and documentation in an electronic format, thereby complying with the 2014 Mandate. Administrative, clinical, and technical leadership partnered to achieve this goal.  OB Trace Vue, our choice of EMR after much research, was found to be the best EMR suited for our growing needs.  Quality standardized documentation is vital in providing good communication among members of the healthcare team. 

Overall Summary  Due to the significant impact that the EMR would have on nursing practice, a team was developed that comprised of management, a nurse educator, and a clinical nurse.  Once it was determined which EMR to use we developed a timeline for training and customization of the product.  The key to successful implementation was dependent upon adequate training. Using the Adult Learning Model, training involved super user sessions, team teaching for end users and hands on time in a test environment.  Physicians were trained on how to access real time nursing assessments by using a hands on interactive training approach.  This practice team also determined that going live all at once with documentation and forms would be too overwhelming and so the “go live” phases were separated into three phases that followed the continuum of the patient’s stay. 

Application of Project and its Future Direction  Implementation of OB Trace Vue has been an ongoing, interactive and evolving process.  An ongoing improvement process through the use of employee training sessions, a corrective action counseling system and system administrator training is a critical factor in the success of our EMR.  Continued nursing and system audits, as well as a collaborative effort with the vendor for upgrades, is also essential to the success.  Feedback from not only the nursing staff but also the physicians has been an essential part in making this transition from paper to an EMR system such a success.  Our goal is to continue to provide the highest quality of healthcare we can to our patients while using a standard language to document this care.

Purpose for the program: Priovide direction on the choosing and implementation of an EMR

Proposed change: Provide nursing with a common language for documentation

Implementation, outcomes and evaluation: ongoing

Implications for nursing practice: improve and secure a common language for documentation

Keywords: Documentation, EMR, Implementation