Philippine Daily Inquirer | 12:29 AM July 13th, 2015
RECORD-KEEPING or documentation is an essential part of nursing practice that has clinical and legal significance at the same time. It is said that quality documentation improves patient care which results in better outcomes, while poor documentation often contributes to poor-quality nursing care (Prideaux, 2011). Nursing documentation, a precursor to good patient care, is a vessel for efficient interdisciplinary communication and cooperation (Ammenwerth, Mansmann, Iller, & Eichstadter, 2003).
Nurses in majority of healthcare facilities in the Philippines still practice paper nursing documentation. A report of the Maryland Nursing Workforce Commission (2007) revealed that such method of documentation reduces the time spent at the bedside for patient care, thus directly affecting outcomes. This is where Nursing Informatics comes in.
Nursing Informatics “aims to improve the health of populations, communities, families and individuals by optimizing information management and communication” (ANA, 2001). It is fundamental in providing cost-effective high-quality healthcare, of which an important component is accurate clinical information.
Thede (2003) explained that electronic information systems provide an avenue for more effective communication and collection of patient health information resulting in more effective patient care. One example of such information system is the electronic health record or EHR, where multiple systems that cross to share data are networked to support efficient information management and communication within a healthcare system. EHR is largely advantageous because it tends to store large amounts of data that are made accessible at the same time in different places. What makes this system more interesting is its ability to provide healthcare teams with clinical alerts and reminders when abnormal parameters are identified in both laboratory and assessment data.
Electronic-based documentation systems would be of great value to Philippine hospitals with a nurse-patient ratio higher than the ideal. When the staffing ratio is high, nurses tend to allot more of their time documenting rather than actually caring for their patients at the bedside. In an electronic-based documentation system, trends in patient outcomes will be highlighted alongside medical and nursing management.
Such systems, while integrating the concepts and theories of nursing science, computer science and information science, propel the entire healthcare delivery system into a practice that is evidence-based and culturally-relevant. These systems should not be regarded as a substitute for clinical judgment or as a predictor of critical illness but as a tool that could help identify life-threatening cases.
Though most of Philippine hospitals are quite far from achieving this, such information systems should be viewed as a crucial facet in promoting a culture of patient safety where the documentation standards help and/or equally meet the standards of medical and nursing care.
—REINER LORENZO JARABE TAMAYO, email@example.com