Module 5: Clinical Decision Making

Among the readings this week, the one that most influenced my perceptions of my clinical decision-making was the Bokel article because it discussed the importance of our electronic health records system. Prior to taking this class I often chose to use the "Narrative Notes" option in my charting system to describe particular patient interactions/interventions. Why? Because it is such an easy option and I perceived it to be a "better," i.e., more fluid and comprehensive, way to explain why I was making particular choices with respect to patient care. I still use "Narrative Notes" to enrich my charting, but I now I am more consciencious about supporting those narratives with entries into the appropriate data entry boxes contained in our electronic medical records. I have come to appreciate how consistent and accruate entries into those boxes not only serves to improve patient care by making the information I enter more broadly accessible to the entire care provider team, but also how important it is for the future of nursing to be recognized for the care we provide and outcomes of our nursing interventions. By taking the time to master the "vocabulary" of the EHR and entering data into its proper place in our computerized systems I am helping our staff to quantify and qualify Nursing's enormous and unsung role in the care delivery process. When, as was my prior habit, I "opt out" of making this effort I'm shortchanging my unit and, prospectively, our profession by making it more difficult to quantify and qualify how I have helped my patient to recover from surgery, to cope with her and/or her infant's illness, and to explain the important role of nurses as educators and care givers who counter a sometimes dehumanizing experience as a hospital inpatient. I view this as especially crucial in my clinical setting where we often have patients who stay with us for weeks, and sometimes months. If I don't make this effort to memorialize my work, it might appear from the computer records that I have done nothing more than perform perfunctory rounds from time to time during the shift. Do I think this reflects my real work? Of course not. This is especially important to me, personally, where a lot of my care-giving philosophy concerns providing care that is minimally invasive of my patients' privacy and my committment to including family and friends in the care delivery process. When I make "Narrative Notes" as a shortcut to explaining the "heuristics" underlying my nursing care it is unlikely to be captured by the automated data collection systems that are meaningful in quantifying and qualifying those services. However, when I take the time to learn our systems better, and to use our computer entry system to record my best efforts, they are better relected in the Hospital's evaluations of our care and assist nursing to be better recognized . . . and maybe better compensated!!