WHO: This tip is especially helpful for beginners and students, or bedside/clinical nurses who are looking to establish or improve data analysis skills
WHY: This is one practical way of building your Nursing Informatics skill, enhancing your value, contributing to your workplace, and improving patient safety/patient outcomes
HOW: Here is a general outline of how to do it; there could be other steps/ways
1. Identify a documentation or workflow problem or issue in your department/workplace. It doesn’t have to be a major issue; it can be something that can be improved slightly or significantly.
2. Formulate a theory of the root cause.
3. Test your theory by gathering data. If you are trying to gather data from the EHR, you will need to:
- identify the location of the documentation (for example, what flowsheet, field/row, etc.)
- identify who is expected to do the documentation (nurse, physician, lab, RT, etc.)
- know the expected documentation (what is compliant; for example; a “yes” answer in a certain field/row)
- know the non-compliant documentation (for example, a “no” answer in a certain field/row or a blank field/row)
- identify any timeline parameters (for example, documentation should be completed within 24 hours of admission to your unit)
4. If you are working at creating an automated report, you may also need to identify other data items and their location/sources, such as:
- any specific order or results that drives documentation
- any “trigger” event that starts the time countdown
- any “stop” event that ends the time countdown
- departments or users that need to be included or excluded from the report (for example: only your unit, all med-surg units, etc.)
5. Summarize the data and present it to your department/workplace leadership in an easy-to-understand format. Use graphs/other visuals if possible.
6. Make an informed recommendation about what needs to be done to improve the documentation/workflow based on the data you’ve collected.