e14 ASPAN NATIONAL CONFERENCE ABSTRACTS

Another challenge brought about by the electronic documenta-

tion is incorporating it with clinical orientation for new staff.

Preceptors were faced with a new challenge; orienting clinical

routines and simultaneously teaching electronic documenta-

tion and navigating the system. The orientation process led to

preceptor and orientee frustrations, decrease in efficiency

and throughput of the orientee and eventually prolonging the

orientation.

The Clinical Documentation Committee responded to the need

to change the orientation process. “Prepare your soldier first

before the battle” was conceptualized. A revised documentation

guidelines, quick reference tool, competency checklist and prac-

tice scenarios were developed. Aside from the 8 hour class pro-

vided by Central Nursing, 6-10 hours are allotted in teaching

unit specific electronic documentation by an assigned coach

and is done prior to starting the orientee in the clinical setting.

The preceptor is mainly focused now on clinical routines and

care. Assessments are done on a regular basis and the need for

further teaching on electronic documentation is determined.

The innovative approach in incorporating electronic documen-

tation with clinical orientation led to increase in preceptor and

orientee satisfaction and morale. Collaboration between two

unit experts led to decreased in length of orientation. Mastery

of both clinical routines and electronic documentation is at-

tained prior to end of orientation.

PACU CHECKLIST: AN ELECTRONIC REMINDERFOR DOCUMENTATION COMPLIANCETeam Leader: Mary Rachel Romero, MSN, RN, CPAN, CAPA

University of Colorado Health System, Aurora, Colorado

Team Member: Michelle Ballou, BSN, RN, CPAN

Background: Electronic documentation requires more tech-

nical skills and intuitive thinking to load patient data. Delays

in entering data can result in corruption of the data and can

cause delays in treatment or errors in treatment, as information

that is not recorded at the time of delivery might be forgotten as

the clinician moves to the next patient encounter (Kohle-Erhser

et al, 2012). It was determined that PACU nurses from this insti-

tution were not meeting the standards on the required docu-

mentation elements resulting in inconsistent data to measure

outcomes and some loss in revenues.

Objective: Investigate utilization of an electronic checklist as-

sists in improving compliance in PACU nursing documentation.

Process of Implementation: Surveys were conducted to

assess staff confidence level with EMR documentation compli-

ance. Chart review and audits were performed to verify compli-

ance. An educational plan was presented to create awareness

on non-compliance to documentation elements as well as to

educate on the use of electronic checklist.

Results and Outcomes:

� Staff confidence level as “Very Confident” went from 6%

to 34 %

� 85% of staff were in favor of the checklist

� Loss of revenues amounting to about $3000 for supplies

was retrieve in an 8 month period

� Missing charges for unit cost is below 1%.

Implications for Practice: Creating a checklist in an EMR sys-

tem improves documentation compliance by serving as a

reminder for nurses, promoting continuity of care. The

reminder also prevents loss of departmental revenues by in-

forming users to be attentive of unit charges.

EFFECT OF ELECTRONIC CHARTING ON PAINDOCUMENTATION IN THE POST ANESTHESIACARE UNITTeam Leader: Melodie Richardson, BSN, RN

Hendricks Regional Health, Danville, Indiana

Team Members: Jackie Harrison, RN, Julie Reed, BSN, RN,

Sherry Cole, BSN, RN, RoxanneNeff, RN, Lisa Coffman, BSN, RN

Identification of the problem: Electronic documentation

standardizes communication to capture nursing interventions

and influences the quality of care provided to patients. Current

methods of pain documentation include paper and electronic

however information in the literature is limited as to which

method completely captures nursing interventions for patients

who are in the Perianesthesia Care Unit following a surgical

procedure.

Evidence-based project objective: The question to be

answered by this project is: What is the effect of using elec-

tronic charting on nursing compliance for pain assessment

and pain reassessment in the Perianesthesia Care Unit?

Methods: Chart audits for pain documentation were per-

formed on a convenience sample of thirty patients who had

hernia repair surgery and were recovered in the Perianesthesia

Care Unit at a 150 bed community hospital. Fifteen charts

were audited using the previous method of paper documenta-

tion and fifteen charts were audited using the currently uti-

lized method of electronic charting. Charts were audited for

assessment of initial pain following the surgical procedure

and presence of pain reassessment following pain medication.

Patients who did not experience pain following surgery were

excluded.

Significance of findings: Audits revealed initial documenta-

tion for pain following surgery was 100% for both paper and

computer charting methods. Documentation of reassess-

ment of pain after administration of medication was 80%

using the paper method and 93% using the computerized

method.

Implications: Findings indicated the computerized charting

method had a higher level of nursing documentation

compliance for pain reassessment following administration

of pain medication. Additional research is needed to

examine the effects of electronic documentation on further

nursing interventions to enhance communication between

healthcare providers and to promote patient safety and

comfort.

UTILIZING CHART AUDITS TO IMPROVE AIRWAYDOCUMENTATIONTeam Leader: Melissa Sayers, BS, RN, CPAN

H. Lee Moffitt Cancer Center and Research Institute, Tampa,

Florida

Team Members: Patrick Cockill, RN, Cindy Chytil, BSN, RN,

Kathy Hosea, RN, Diane Morgan, BSN, RN, CCRN, Elizabeth