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Health Science

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Dec 6, 2023

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docx

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Concerns and Workarounds with a Clinical Documentation System Colorado State University Global HCM570: Healthcare Information Systems April 9, 2023 Concerns and Workarounds with a Clinical Documentation System 1

2 Computerized Physician Order Entry (CPOE) permits physicians to enter prescription orders electronically, potentially improving patient safety by reducing medication ordering errors. These technologies alert physicians to potential drug interactions and impending duties. CPOE systems provide new capabilities, but their inadequate usability may frustrate users and discourage their adoption. This paper discusses the CPOE system challenges and workarounds at Garrison Children's Hospital and provides recommendations for implementing and enhancing clinical documentation. Challenges and Problems The usability issues of the new clinical documentation system challenge the nurses at Garrison Children's. Initially, the nurses were unhappy with the insufficient flowsheets. Flowsheets are integrated EHR documentation tools intended to aid practitioners, and it provides data for medical decision support and reporting on quality and safety (Waitman et al., 2011). Adapted to each user's clinical workflow, flowsheets effectively save time and promote consistent documentation, which may reduce medical errors. Furthermore, usability issues are inconsistent documentation and the absence of a content standard. A lack of consistency and standardization in documentation may require clinicians to seek information from multiple sources or repeatedly document the same information, which can reduce COPE's effectiveness. Another problem is the resistance of the nurses to the change since they believe they do not comprehend why the organization is automating clinical documentation or what it intends to achieve. Nursing staff members' resistance to change makes the transition to electronic documentation difficult. The attitudes of nurses have a significant impact on their willingness to embrace and adopt electronic clinical documentation (Waitman et al., 2011). Nurses' confidence in their ability to adapt to new technology and optimism about its potential to improve patient

3 care are crucial to the success of computerized system implementations. Furthermore, the implementation failed to account for staff members' computer literacy, the complexity of the documentation, or the standard operating procedures in place. Implementation of a Computer Physician Order Entry (CPOE) Change management is needed to implement CPOE. Its adoption must consider technological and human factors. COPE usability must be improved to boost CPOE system adoption. Usability refers to how easy it is to achieve goals. Errors, inefficiency, and rejection might result from a poorly utilized CPOE system (Sengstack & Gugerty, 2004). User-centered design can solve usability issues, which addresses end users' demands and limits throughout the design process (Wager et al., 2022). Change management helps nurses adapt to technology. Electronic clinical documentation will bring changes that may cause nurses to experience dread, concern, and dissatisfaction. These feelings may make nurses resist electronic systems. Nurse leaders should communicate well about the change and its implementation to reduce nurses' resistance and promote positive attitudes. Nurses should be informed about the CPOE's impacts, benefits, and necessity. Training demands and user skill levels must be assessed before COPE system deployment. Training should be tailored to each unit or clinician based on user skill levels and needs. Clinical Documentation in Pediatric Versus Adult Patients The clinical documentation for children and adults is distinct. Pediatricians have different documentation requirements than adult physicians. In children, condition-specific evaluations are less common than in adults. Children had a lower proportion of documented pulse oximetry, monitoring administration, and pain rating among patients with respiratory, cardiac, and traumatic symptoms than adults (Cercone et al., 2023). Also, compared to other specialists,

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