The Electronic Medical Record in Our L&D: Working Out the Kinks

Purpose for the program:

Innovative technology has resulted in the emergence of the Electronic Medical Record (EMR) as the standard in healthcare documentation. Our labor and delivery has witnessed many positive changes. Patient information that might have a significant impact on our plan of care could have been omitted on the paper medical record. Healthcare professionals no longer struggle to interpret illegible entries. This improvement positively influences patient safety.

The program used in our L&D is a product of Epic, called Stork. Many nurses, accustomed to reviewing a paper chart to be sure that all expected components of that record were present and complete, have encountered some challenges. In Stork, nurses navigate the chart in many different directions. This approach allowed for important sections of the chart to be overlooked. Documentation deficiencies easily identified before the use of EMR are easily left unnoticed in the electronic system.

This system made it challenging for the departing nurse to systematically inspect her documentation for flaws. Many hours were spent reviewing charts and discussing the challenges at unit meetings. Improvement was often fleeting, only to have the same defects arise again which required more time educating and reminding staff via emails. Our nurses needed two things: A list of required documentation and a standardized order for gathering and recording the information.

Proposed change: A list of required documentation and a standardized order for gathering and recording the information.  

Implementation, outcomes and evaluation: A "Report Checklist" was created. Report in our unit is given at the bedside in order to include the patient and family during this exchange of information, allow correction of information to and reinforce the plan of care in the minds of all present. During report, both nurses review all components of the Stork chart listed on the checklist. The nurse handing over care,aware of deficits in the record,can correct incomplete documentation in real time.

Implications for nursing practice: The goal of this initiative is to standardize the order in which assessment data are reviewed during report and reveal opportunities to correct deficiencies. In addition, cost savings should occur as the nursing hours spent reviewing charts, formulating action plans for improvement and re-educating staff will be reduced. Daily reinforcement of the actions required by the RN when caring for our patients (specifically monitoring and documentation of patient temperature every two hours after rupture of membranes ) will improve safety.

Keywords: Checklist; deficiencies electronic medical record; bedside report