Change and Evidenced-Based Practice on Medical Records Management

Pages:

8

Academic Level:

University

Paper Type:

Annotated Bibliography

Discipline:

Nursing

Describe a change that you would like to initiate within the profession of nursing, your present or past clinical practicum(s) or work setting. Discuss the proposed change and present evidence – based research/best practices to support this change from a minimum of three sources.

Let the essay be about medical records

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Change and Evidenced-Based Practice on Medical Records Management

 

 

Student Full Name

Institutional Affiliation

Course Full Title

Instructor Full Name

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Change and Evidenced-Based Practice on Medical Records Management

Abstract

Medical records include numerous documentation regarding a patient, including their history, diagnostic test results, clinical findings, daily notes, operation notes, post-operative care, preoperative care, and the medications a patient is taking.  Failure to manage medical records effectively can harm the patient and also make a healthcare facility face lawsuits. Thus, in this study, I will explain the causes of medical record mismanagement in an institution I worked at, giving examples and suggestions on how to handle the issue. Additionally, I will support the study with journal articles on medical reporting errors and incorporate the findings in the recommendations for change in the nursing institution.

Keywords: Medical Records, Documentation, patient safety, change

Introduction

Traditionally, the management of medical records was simple and straight forwards. All the information about a patient was recorded on paper charts and files, then stored in the various hospital cabinets. Nonetheless, with the significant advancement in technology, medical practices have changed significantly, and so has the management of these records. Currently, most health professionals in the U.S. use EMR systems for the management of medical records. Additionally, the significant advancement in diagnostic and analytic strategies means that the patient information an institution needs to store has increased significantly. It is the legal and ethical obligation of all healthcare providers to manage medical records effectively. Medical providers need to input, store, and secure all patient data effectively. Poor medical record management can result in significant errors, treatment lapses, missed diagnoses, and several other events which can be life-threatening for the patient. One change I would like to initiate i is the effective management of medical records because I worked in an institution where records were poorly managed.

Improvement in Medical Record Management

Medical record management refers to a system of protocols and procedures that govern all patient information from the time it is recorded to its storage, security, and usage. I worked in an institution where medical health records were poorly managed. This not only put the life of a patient at risk, but there were instances when some patients opted to file lawsuits against the institution. Additionally, most insurance companies need proper record-keeping to prove that the compensation is well justice.

For instance, some medical practitioners were so fast in doing a procedure on the patient to help them feel better that they failed to record whether the patient gave consent. This ended up being challenging to get compensated by insurance companies because they argued that the procedure was only done because the hospital was money-oriented. Additionally, a doctor could fail to include the date, name, and even their signature on a prescription drug. In some instances, the patient misused the drug, and the family ended up blaming the medical practitioner for not being clear on the prescription. Some medics used to copy-paste some medical records, and they could end up copy-pasting in the wrong patient records (Tsou et al., 2017). In some instances, the hospital management upgraded the Electronic medical record without giving the staff practical training on using the upgraded system. This resulted in a significant number of errors.

Examples of Causes of Medical Record errors and the Recommended Changes

Shortage of Notes: Some medical practitioners assumed that some of the procedures are insignificant, hence ignored and failed to record them. The medical record needed to include every information a patient disclosed and every procedure carried out on the patient (Tasew et al., 2019). Also, any activity concerning the patient needed to be recorded comprehensively. Failure to do this meant the information was inadequate and incomplete. For instance, some professionals could decide not to include the comprehensive history of the patient. It was supposed to consist of family history, drug use, medical history, allergies, and the name of other healthcare providers who had been treating the patient. Failing to do this could result to a patient getting prescribed two reacting medicines. All medical practitioners needed training on why it was crucial to record every piece of information. Similarly, medical practitioners were supposed to be trained on how to use the systems effectively. In some instances, the medics could post information in the wrong section, making it hard to retrieve the data.

Illegible handwriting: Despite most of the medical records in the healthcare institutions being electronic, some instructions or information were handwritten. When a doctor instructed a nurse to give a patient a certain medication, but the handwriting was illegible, it could result in the wrong dosage (Brits et al., 2017). There are instances this ended up being hazardous to the patient, especially because most nurses were afraid of communicating with the doctors for clarification in fear of getting scolded. To amend this challenge, all medical instructions or records should be typed.

Copy Pasting is another significant error that happened in the healthcare institutions. Some medical practitioners never read the patient's health history and instead, they copy-pasted rather than typing. Additionally, some copied and pasted discharge summaries. However, this could be hazardous because the medic could copy symptom history of a previous condition that the patient was not going through then, which could result in wrong diagnoses or wastage of time and resources testing for wrong symptoms (Tsou et al., 2017). The best strategy which could help in handling the issue would have been always ensuring the copy pasted work was monitored and assessed by a different person. The assessment needed to be done regardless of the job position of the individual who input the data. Going through the information written by another person would help in pointing out any illogical information that could have been pasted by mistake.

Who should be involved in the Change Process

The medical practitioners, institution management, and hospital board of governance needed to be involved in the change process. The medical practitioners were the ones who mainly made, stored, and used these records. Thus they needed to be involved in the change process. That includes doctors, physicians, nurses, nursing assistants, medical assistants, pharmacists, and even therapists. Moreover, the management was important in this change process because it was in charge of making most policies. Understanding the problem would make the management know why it was urgent and thus push it forward to the hospital board. The hospital’s board could scrutinize to see whether there could be a hidden agenda for the proposal and the transparency in the budget and action plan.

Identify Anticipated Barriers to the Change and Strategies to Overcome the Challenges.

Similar to any other transition, there could be a possibility of some people resisting the change. For instance, the doctors who gave nurses handwritten instructions could argue that typing takes a lot of time. Similarly, the auditing strategy where everyone's work needs to be reviewed by a different individual could be resisted. Some highly ranked staff can argue that the institution doing that makes it appear they do not trust their competence. The resistance to change could be handled by a training and sensitizing the staff on the importance of the change process. Moreover, it is crucial to involve the staff in the strategies and ask for their suggestions on avoiding medical recording errors.

There could be a financial barrier also. The management could argue that it would be costly to train all the staff to use the system. Consequently, only the various department heads get trained, then they are tasked with training the juniors. That is challenging because they also have their daily tasks to do in addition to training. Consequently, the staff gets inadequate training, which can adversely affect their effectiveness in medical record management. To handle this challenge, the team in charge of this change proposal should justify the management on how costly the medical record errors can be. It affects quality service delivery which can result in misdiagnoses or failure to get the right retreatment. Consequently, the institution can lose funds, insurance refunds, or even face lawsuits.

Discuss Implementation of the Change

Change can be a complicated process in the hospital setup; thus, it is necessary to implement it professionally. According to Lewin's change model, the process comprises three stages: Unfreezing, changing, and refreezing. Unfreezing entails the creation of awareness to all the relevant parties of how the current strategies used in managing medical records hinder the hospital from achieving its objective of offering quality health care (Hussain et al., 2018). Communication is crucial in this step because it will help employees understand the need for the change and thus get motivated to embrace it. The employees should understand why they are changing how they make medical records and be trained on using the systems accordingly. This can take up to three months.  

The second step is changing, which Lewin argues is the actual transition process. In this step, people started learning new behaviors, which are filled with fear and uncertainty. Some individuals can feel that getting their work checked before saving is a waste of time or being subjected to scrutiny (Hussain et al., 2018). Thus, education, communication, support, and time are crucial steps in this step. In the entire step, staff should get reminded of the need for change and how it will be beneficial. This can take up to six months.

Thirdly, it is the refreezing step, where the people accept the new norm. The step entails cementing the new strategies to the organization's culture and maintaining it as the way of doing or thinking. In this step, the management should acknowledge the employees for the changes they have implemented and even offer rewards to reinforce the behavior (Hussain et al., 2018). Also, there should be frequent monitoring and evaluation to evaluate the effectiveness of the strategies and areas that can be improved.

Evidence-Based Practice

EBP entails incorporating clinical expertise, research evidence, and the preferences of a patient to ensure nurses offer individualized patient care.  In this situation, the PICOT question could be; For nurses caring for patients with chronic ailments (P), how do medical record management errors (I) affect the testing and diagnoses (O) of the patient over eight weeks (T). The format makes it possible to have a comprehensive search of the question. Various research studies support the need for ensuring medical record management is done accordingly.

Tasew et al., (2019) did a study on investigating the documentation practices amongst nurses in public hospitals. From the study, which had 317 voluntary participants, 47.8% of the respondents showed that the nursing care documentation was inadequate. That shows that in a significant number of healthcare institutions, there is a shortage of notes. The main reason was the employees did not understand the importance of recording all the medical activities about a patient. Some respondents argued that there was so much work, and they lacked time to document their activities.  That is similar to the issue in the institution I was working in because some medical practitioners do not understand how important comprehensive documentation is. Thus, the institution should train the staff on the importance of keeping comprehensive documentation.

Tsou et al. (2017) did a literature review of 51 publications on the safe practices which need to be incorporated when copy-pasting medical records. From the study, although the copy and paste function helps save the time used to type and can promote efficiency, it could also result in inaccurate documentation. From the study, about 3% of all errors that resulted in missed diagnoses resulted from the copy and paste function. Copy-pasting can result in documentation in wrong patient charts, error propagation, internal inconsistencies, and note bloat. Thus, to handle the copy and pasting challenge in medical reporting, the institution needs to offer enough staff training and education and ensure strict monitoring and assessment of the practices.

Brits et al. (2017) did a study on how illegible handwriting can cause medical errors. Generally, doctors are associated with illegible handwriting, where other parties have issues reading and interpreting their work. In this study, the prescriptions made by 20 doctors were read by various nurses, pharmacists, and other doctors to evaluate the accuracy. From the 300 individuals who read the instructions, 88% of the doctors accurately compared to 75% of the pharmacists and 82% of nurses. This shows that pharmacists, despite being the ones to issue the prescribed medicine, read the instructions worse, resulting in a critical mistake that could be lethal. Approximately 7000 people die annually as a result of the illegible handwriting by doctors. Therefore, it is important for medical institutions to resort to typed instructions, whether prescription, dosage amount, or any other notes, to increase clarity. Also, there is a need for good communication between doctors, the primary caregivers, and other staff to make it easy for consultation.

Recommendation for Nursing Practice

When healthcare professionals use the copy and paste option, there is a need to monitor and assess frequently to ensure that the right thing is being done. This can be hectic, and some people find it intimidating because they assume the institution does not believe their judgment. However, training should be done on how to copy-paste effectively and sensitize the staff on how hazardous wrong copy and pasting can be to the patient's safety.

Additionally, medics should be trained on the importance of comprehensive documentation. They should also be trained individually by professionals on using EMR to ensure they do it effectively. Moreover, healthcare institutions should have informatics personnel who can be consulted if an individual does not understand how to use the system accordingly.

The institution should ensure all prescriptions, dosages, and instructions are typed to avoid illegible handwriting issues on medical records. Some can find it time-consuming, but they should be sensitized to its importance. Additionally, a culture where communication regardless of ranks is allowed is crucial because it ensures people can consult any unclear instruction.

 

 

References

Brits, H., Botha, A., Niksch, L., Venter, K., Terblanché, R., & Joubert, G. (2017). Illegible handwriting and other prescription errors on prescriptions at National District Hospital, Bloemfontein. Professional Nursing Today, 21(2), 53-56. 

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin's change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-127.

Tasew, H., Mariye, T., & Teklay, G. (2019). Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC research notes, 12(1), 1-6.

Tsou, A. Y., Lehmann, C. U., Michel, J., Solomon, R., Possanza, L., & Gandhi, T. (2017). Safe practices for copy and paste in the EHR. Applied clinical informatics, 26(01), 12-34.