NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Name

Capella university

NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner

Prof. Name

Date

EHR Data Entry Protocols

Purpose

This policy outlines the requirements for electronic documentation within the ambulatory healthcare electronic health record (EHR) system, ISalus. Proper adherence to these protocols ensures accurate and effective documentation that supports patient care, facilitates communication, and aligns with best practices in reimbursement, risk management, and coordination among healthcare teams.

EHRs serve as a legal record and a tool for meeting regulatory requirements for billing, clinical practice, and standards of care. Proper data entry practices are crucial, as EHRs differ from traditional handwritten notes. While they offer tools to streamline documentation, they also introduce potential risks, emphasizing the need for accuracy and attention to detail.

Population Affected by the Policy

This policy applies to all users of the EHR system within the organization, including healthcare providers, nurses, technicians, therapists, and other staff members involved in patient care. The policy benefits patients by minimizing errors and enhancing safety during care delivery. Compliance ensures equitable application, regardless of demographic factors such as age, gender, or race.

Policy Statement

Objectives

The healthcare organization is dedicated to improving patient safety through the implementation of standardized EHR data entry protocols. These protocols aim to:

1. Ensure the accuracy, completeness, and timeliness of data entered into the EHR.
2. Reduce the risk of errors associated with improper EHR use.
3. Provide clear guidelines for data entry, aligned with best practices and regulatory standards.

Training will be mandatory for all employees within 30 days of hire and annually thereafter. Additional training will be provided when significant system updates occur. Compliance monitoring and audits will ensure adherence to the policy.

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Table: Overview of EHR Data Entry Protocols

Heading	Description	Actions
Guidelines	Clear expectations for data accuracy, timeliness, and relevance to patient care.	Develop detailed instructions for verifying data, double-checking critical points, and ensuring updates.
Training Requirements	Comprehensive training for all staff on EHR data entry protocols.	Include purpose, application, and troubleshooting strategies during training sessions.
Monitoring and Evaluation	Regular compliance audits and evaluations to measure the policy’s effectiveness in improving patient safety.	Assess adverse events, patient satisfaction, and data quality to adjust protocols as needed.

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Procedure

1. Training Development and Delivery

   • Office/practice managers will create training programs based on policy guidelines.
   • Training will be delivered before any EHR use to ensure competency.
   • Employees must meet set standards; non-compliance will result in corrective actions.

2. Data Entry Process

   • Adopt a two-step data entry system: team members validate peer-entered data for accuracy.
   • Limitations include avoiding copy-paste functions except for verified updates to records.

3. Timeliness and Supervision

   • Notes must be completed and signed within 24 hours.
   • Supervisors will run weekly reports to address deficiencies.
   • Providers retain sole authorship of their notes unless using an approved scribe.

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References

Agency for Healthcare Research and Quality. (2018). Patient satisfaction surveys. www.ahrq.gov/patient-safety/settings/primary-care/resources/quality-improvement/patient-satisfaction-survey/index.html

Antonacci, G., Lennox, L., Barlow, J., Evans, L., & Reed, J. (2021). Process Mapping in Healthcare: A Systematic Review. BMC Health Serv Res, 14(21(1)), 342. https://doi.org/10.1186/s12913-021-06254-1

Ash, S. J., Corby, S., Mohan, V., Solberg, N., Becton, J., Bergstrom, R., Orwoll, B., Hoekstra, C., & Gold, J. A. (2020). Safe use of the EHR by medical scribes: a qualitative study. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocaa199

Bani, I. W., Akour, I., Ibrahim, A., Almarzouqi, A., Abbas, S., Hisham, F., & Griffiths, J. (2020). Privacy, confidentiality, security, and patient safety concerns about electronic health records. International Nursing Review, 67(2), 218–230. https://doi.org/10.111/inr.12585

Bates, D. W., & Gawande, A. A. (2017). Patient safety and electronic health records. New England Journal of Medicine, 376(3), 193–195.

Bersani, K., Fuller, T. E., Garabedian, P., Espares, J., Mlaver, E., Businger, A., Chang, F., Boxer, R. B., Schnock, K. O., Rozenblum, R., Dykes, P. C., Dalal, A. K., Benneyan, J. C., , L. S., Lehmann, Gershanik, E. F., Bates, D. W., & Schnipper, J. L. (2020). Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR. Applied Clinical Informatics, 11(01), 034–045. https://doi.org/10.1055/s-0039-3402756

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Boyle, D. K., Barenholdt, M., Adams, J. M., McBride, S., Harper, E., Poghosyan, I., & Manges, K. (2019). Improve nurses’ well-being and joy in work: Implement true interprofessional teams and address electronic health record usability issues. Nursing Outlook, 67(6), 791–797.

Buitron de la Vega, P., Losi, S., , L., Sprague Martinez, Bovell-Ammon, A., Garg, A., James, T., Ewen, A. M., Stack, M., Carvalho, H., Sandel, M., Mishuris, R. G., Deych, S., Pelletier, P., & Kressin, N. R. (2019). Implementing an EHR-based Screening and Referral System to Address Social Determinants of Health in Primary Care. Medical Care, 57, S133–S139. https://doi.org/10.1097/mlr.0000000000001029

Krick, T., Huter, K., Domhoff, D., Schmidt, A., Rothgang, H., & Wolf-Ostermann, K. (2019). Digital technology and nursing care: a scoping review on acceptance, effectiveness and efficiency studies of informal and formal care technologies. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4238-3

Lopez, K. D., Chin, C.-L., Azevedo, R. L., Kaushik, V., Roy, B., Schuh, W., Banks, K., Sousa, V., & Morrow, D. (2021). Electronic health record usability and workload changes over time for providers and nursing staff following the transition to new EHR. Applied Ergonomics, 93.

Mandl, K. D., & Kohane, I. S. (2020). Data citizenship under the 21st Century Cures Act. The New England Journal of Medicine, 382(19), 1781–1783.

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Melnyk, B. M. (2018). Evidence-based practice in nursing and healthcare: a guide to best practice (, Ed.). Wolters Kluwer Health.

Mitchell, M. B., & Hull, S. C. (2020). The Alliance for nursing informatics: Building on 15 Years as the single voice for nursing informatics. Computers, Informatics, Nursing, 38(1), 5–7.

Name, M. T., Chacko, J., Surace, A. E., Sinha, I. P., & Hawcutt, D. B. (2019). A systematic review of the effects of implementing clinical pathways supported by health information technology. Journal American Medical Informatics Association, 26(4), 356–363. https://doi.org/10.1093/jamia/ocy176

Quinn, M., Forman, J., Harrod, M., Winter, S., Fowler, K. E., Krein, S. L., Gupta, A., Saint, S., Singh, H., & Chopra, V. (2018). Electron health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. Diagnosis, 6(3), 241–248. https://doi.org/10.1515/dx-2018-0036

Rosen, M. A., Diaz-Granados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist, 73(4), 433–450. https://doi.org/10.1037/amp0000298

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Shim, J. S., Kanny, J., & Koppel, R. (2019). Electronic health records and patient safety. A review. Journal of American Medical Informatics, 26(1), 4–17.

Singh, H., & Sitting, D. F. (2020). A Sociotechnical Framework for Safety-Related Electronic Health Record Research Reporting: The SAFER Reporting Framework. Annals of Internal Medicine, 172(11_Supplemental.), S92–S100. https://doi.org/10.7326/ml9-0879

Sittig, D. F., Sengstack, P., & Singh, H. (2022). Guidelines for US Hospitals and Clinicians on Assessment of Electronic Health Record Safety Using SAFER Guides. JAMA, 327(8), 719–720. And also our expert help you in NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

Tschannen, D., Alexander, C., Tovar, E. G., Ghosh, B., Zellefrow, C., & Milner, K. A. (2020). Development of the nursing quality Improvement in practice tool. Journal of Nursing Care Quality, 35(4), 372–379. https://doi.org/10.1097/NCQ.0000000000000457

Tubaishat, A. (2017). The effect of electronic health records on patient safety: A qualitative exploratory study. Informatics for Health and Social Care, 44(1), 79–91. https://doi.org/10.1080/17538157.2017.1398753

Windle, J. R., Windle, T. A., Shamavu, K. Y., Nelson, Q. M., Clarke, M. A., Fruhling, A. I., & Techeng, J. E. (2021). Roadmap to a more useful and usable electronic health record. Cardiovascular Digital Health Journal, 2(6), 301–311. https://doi.org/https//www.ncbi.nlm.nih.gov/pmc/articles/PMC8890352/

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