Quick Tip: Volunteer for EHR Chart or Clinical Documentation Audits

Try asking your department/unit manager if you can volunteer for any EHR chart or documentation audits.

WHO: This tip is especially useful for beginners with no formal Nursing Informatics experience yet.

WHY: Department/unit managers often keep track and/or have to report on a number of patient safety or quality of care issues and goals. Some of these reports can be extracted straight from the EHR (for example, Epic has lots of online reports and dashboards) or can be tracked and analyzed using Excel or some other tool. Even if a report has already been created and been in place for a while, clinicians may be asked (or may need to) do some random validation to ensure that the report(s) are capturing the appropriate data and the report logic is correct (or still correct after a change happens). This validation is especially necessary when a change in workflow and/or EHR functionality has recently been implemented, for example after a major upgrade that involved introducing new flowsheet rows or documentation fields/tools, etc.

WHAT’S THE VALUE: This has value because it helps you become better acquainted with policies and how they are put into practice when it comes to EHR functionality. It also gives you an idea of the patient safety or quality compliance goals and metrics that are important to your department or organization. Plus, this gives you some practice with identifying, defining, managing and communicating data, information, knowledge, and wisdom in nursing practice – which is a key concept of Nursing Informatics. WIN!

SOME EXAMPLES of clinical documentation that you can help validate or audit:
1. Do staff nurses on your unit document the patient’s fall risk upon assessment (or within the time frame defined in your policy, etc.)?

2. Do staff consistently document the patient’s pain score before *and* after giving PRN pain medication (you can define a time frame as well – such as 30 minutes before to 1 hour after the med administration).

3. Are nurses calling the provider/attending within 1 hour of receiving a call from Lab staff regarding a critical lab value?

There’s lots more! Be creative and be engaged and you can help meet the needs of your department while helping improve patient safety and/or the quality of care – and at the same time start building up your Nursing Informatics-related skill set in the process.