Nursing Documentation in the Electronic Age
To successfully implement change within an organization several factors must be present: A shared vision and mission, effective leadership structure, and a culture that encourages and rewards change. (Gesme & Wiseman, 2010). According to Nick A. Fabrizio, PhD, “The key to transformational change or any change is to have leadership that is able to understand it, support it, explain it, and move the organization to commit to it. That is 95% of the success of any change,”. (Gesme & Wiseman, 2010).
1. ADRESSING THE CONCERNS
A. Leadership
• Transformational leadership: Transformational leadership embraces a shared vision and mission. The mission is supported through open communication, motivation, encouragement and praise. (Nursing leadership, 2014).
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Openly communicating the vision, plan and reason for implementing change, staff involvement, expectations and responsibilities, and the overall benefits for the patients. Show individuals how the change is going to help them do their jobs more effectively or how it supports the direction of the practice. (How to implement change in practice, n.d.).
2. ELECTRONIC DOCUMENTION AND PATIENT-CENTERED CARE
The individual needs of patient’s guide healthcare practices. Flow sheets and electronic documentation play a vital role in communicating the patient’s condition and organizing their care according to the presented needs. (“The right balance”, 2017). EHRs utilize information technology to manage, store, and present readily available clinical information for seamless communication among patients and their healthcare team. (Ventres & Frankel, 2010). Therefore, the implementation of electronic documentation could enhance and positively contribute to patient centered care.
3. ADVANCEMENTS IN INFORMATION TECHNOLOGY AND PATIENT