Introduction
The use of technology in healthcare provision has gained significance in the recent times. Technology is known to make work easier. Consequently, the importance of its adoption cannot be overemphasized. It should be noted that there are several innovative ways that nursing facilities can improve service provision. Various patient initiatives such as core measures tracking, handoff communication, medication reconciliation, point-of-care documentation and immunization tracking are critical in this regard. For that reason, this paper endeavors to consider how the adoption of point-of-care documentation bears on the nursing profession.
The problem
Communication plays an integral role in any organization. Effective communication allows organizations to coordinate their activities towards ensuring goal attainment. Most clinical facilities have adopted Electronic Health Records (EHR), which work better alongside point of care documentation. In the healthcare facility where I work, there is a lack of consistency in communication. This implies that communication is ineffective. In my assessment, the absence of Point of Care (POC) plays a role in the current state of affairs. Thus, it is necessary to adopt the Point of Care documentation to help in redressing the situation. Point of care documentation reflects the ability among clinical practitioners to document information while at the same time interacting and delivering services to patients (Kohle-Ersher, Chatterjee, Osmanbeyoglu, Hochheiser and Bartos, 2012). Adopting the system would be useful in documenting and integrating work within clinical facilities.
Goals of the Initiative
Goals of integrating technology into any endeavor centers on easing work outcomes. From the problem definition, it is clear that inconsistencies undermine work delivery. Consequently, the adoption of POC is meant to clear such inconsistencies. For that reason, the goal of adopting POC is to streamline communication.
With a clear communication path, the workflow at the clinical facility would improve significantly. As (Duffy, Kharasch and Hongyan, 2010) observed, POC documentation alters the practice of clinicians as it affects communication and workflow processes. Having POC documentation tools allows nurses to move freely without having to go back to their offices to check some details. In addition, nurses are able to avoid redundant engagements since data is sourced at the point of need. This demonstrates that such requirements as transcription are done away with. Hence, another aim of adopting POC documentation is to improve workflows.
Adopting POC documentation may become necessary to improve the safety of patients. Kohle-Ersher, Chatterjee, Osmanbeyoglu, Hochheiser and Bartos (2012) observed that a hindrance of face-face interaction between a nurse and patient may lead to data corruption leading to mistakes in treatment. Thus, allowing clinicians to document information at the point of delivery of services enhances accuracy, timely interventions, and overall patient safety. Consequently, error reduction is one of the objectives of adopting POC documentation.
The need to promote collaboration is critical in clinical environments. As pointed earlier, inefficient communication contributes to medical errors. Adopting point of care documentation encourages continuity of quality care as it improves communication between patients and nurses. POC documentation optimizes the flow of information amongst clinicians, an aspect that promotes their ability to collaborate (Cheevakasemsook, Chapman, Francis and Davies, 2006).
The final goal considered centers on the need to allow adequate time for nurses and patients. Yeung, Lapinsky, Granton, Doran and Cafazzo (2012) found that POC documentation could reduce between 25 and 50 percent of the time nurses wasted on manual data documentation. Thus, adopting this initiative is intended to reduce time wastage, and allow adequate time of sharing between nurses and patients.
Source of the Data and Description of Output
For the initiative to work properly, data is required. The data required comes from patients as well as clinicians. This implies that existing systems would play a role in feeding data to the new initiative. However, since on point data is required, nurse entries are expected to play a significant role. The output of the initiative is primarily condensed data about healthcare services. Hence, the outcome is to be both electronic and manual copies for easy access. Printed reports and online displays will be available for concerned stakeholders.
Application of the Systems Development Life Cycle
Despite the many changes to the systems development life cycle, the system remains a steadfast and reliable mechanism to the development of software (SDLC). The SDLC is a conceptual framework that describes stages in implementation of information systems (Whitten and Bentley, 2008). Although there are various models of SDLC, there is consensus that the following stages are significant.
Here below, six stages of SLDC are presented as outlined by Whitten and Bentley (2008). The first stage entails an evaluation of the existing system. This allows for the identification of deficiencies. Interviewing users of the current system plays a role in evaluating the system. In the second stage, new requirements are defined. Particularly, this emanates from the existing deficiencies. It is also notable that specific proposals for improvement are made. In the third stage, the new system is designed. The design encapsulates the physical construction, communication, programming, hardware, security concerns and operating systems. In the fourth stage, the system is developed. Users are also trained on using the system. At the stage, performance is tested to ensure that it meets expectations. Any discrepancies must be corrected at the stage. In the fifth stage, the system is rolled out for use. This entails replacing the old with the new system. The final stage centers on evaluating the running of the new system. Moreover, system users are kept up-to-date in addition to ensuring appropriate system maintenance.
Benefit of the Technology
The recurrent theme in the paper is accuracy of information and timely deliveries of services. Since the accuracy of information is significant, it is alleged that POC documentation has the advantage of allowing workers to care for patients, monitor clinical effectiveness and account for delivered billing services. In addition, POC technology assembles data which is put at one point, an aspect that allows for effective distribution of important information. In a nutshell POC simplifies the communication muddle that most organizations find themselves wading through.
It is also established that POC documentation has the potential of allowing nurses to move without having to go back to their offices to check some details. Moreover, nurses are able to avoid redundant tasks since information is stored at a point accessible at any place or time. Hence, adopting POC documentation brings the benefits of improving workflows.
Adopting POC documentation may also contribute towards improving the safety of patients. As observed by Cheevakasemsook, Chapman, Francis and Davies (2006), hindering face-to-face interaction between a nurse and patient might lead to the corruption of information leading to treatment mistakes. This problem is eliminated since information is documented at the point of delivery of services, hence enhancing accuracy, timely interventions and patient safety. Therefore, the system has the benefit of reducing treatment errors.
As established, POC documentation avails patient information to caregivers at any point or time they would prefer to access information from the system. This implies that caregivers can access such information from their homes or anywhere through the continuum of care. Such a provision is critical in allowing caregivers an opportunity to reexamine issues whenever they deem necessary.
Users of POC documentation would enjoy other benefits such as:
- Increased reimbursements since there is complete accurate pool of care information
- Reduce time spent in information controls
- Freeing staff to dedicate more time to care extension and afford germane and opportune information for other care workers
- Avoid errors since there is an automated documentation
- Ensure that there is compliance with documentation requirements
Approaching Colleagues to Transform Practice
Concerted efforts from all stakeholders are mandatory if the initiative is to succeed. That aside, accomplishing the goal requires that one takes a computer to the bedside to document the following (Whittaker, Aufdenkamp and Tinley, 2009):
• When admitting a patient
• When performing assessments and routine care
• When entering orders
• When accessing other information required to perform patient care. These include labs or reports
Caregivers need to mind the needs and perceptions of patients when charting. This is expected to allow patients feel welcome and loved. Nurses should also develop the habit of supporting POC documentation. For the POC documentation to prevail, nurses and other practitioners are advised to avoid:
• Writing notes about care given to patients when entering later or at the end one’s shift.
• Depending on your memory on making computer entries later.
Finally, when initiating such a system, all caregivers at a facility should be informed about the associated benefits. However, a transformational leadership approach could be required to spur workers/colleagues into embracing POC documentation.
Conclusion
This paper demonstrates that adopting POC documentation is necessary in a bid to ease communication and enhance nursing outcomes. It is clear that the adoption of such a technology would enhance service delivery by reducing time wastage while increasing coordination of work activities. Hence, the implementation of the initiative is supported.
References
- Cheevakasemsook, A., Chapman, Y., Francis, K., & Davies, C. (2006). The study of nursing documentation complexities. International journal of nursing practice, 12(6), 366–74.
- Duffy, W. J., Kharasch, M., & Hongyan, D. (2010). Point of Care Documentation Impact on the Nurse-Patient, 34(1)
- Kohle-Ersher, A., Chatterjee, P., Osmanbeyoglu, H. U., Hochheiser, H., & Bartos, C. (2012). Evaluating the barriers to point-of-care documentation for nursing staff. Computers, Informatics, Nursing: CIN, 30(3), 126–33.
- Whitten, J. L., & Bentley, L. D. (2008). Introduction to systems analysis and design. Boston: McGraw-Hill.
- Whittaker, A. a, Aufdenkamp, M., & Tinley, S. (2009). Barriers and facilitators to electronic documentation in a rural hospital. Journal of Nursing Scholarship, 41(3), 293–300.
- Yeung, M. S., Lapinsky, S. E., Granton, J. D., Doran, D. M., &Cafazzo, J. A. (2012). Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units. Journal of Clinical Nursing, 21(7-8), 975–982.
