By Carel Mountain, DNP, RN, CNE
The old saying “If it wasn’t documented; it wasn’t done” still holds true today. Just because we have moved away from paper charting, doesn’t mean that nursing students no longer need to be guided through the process of documentation. Although you may have mixed feelings about the Electronic Medical Record (EMR), it is here to stay. That means it's our job, as instructors, to make sure students use this tool as accurately as possible in recording the care they provide.
In the not too distant past, students wrote their charting entries on a piece of paper, reviewed it with the instructor, and then proceeded to hand write in the permanent record. Now, assessments are completed with the click of a mouse and narrative notes barely exist. Because of this, students don’t always know how and where to chart. Using the EMR has left students with less guidance in charting, which doesn’t provide a solid foundation when they move to the working world. An Academic EMR gives teachers the chance to assist students on the path to proficient documentation.
Why use an Academic EMR?
Being able to practice documentation is an important factor in developing charting skills. Academic EMR’s provide a place where students can not only work on these skills, but they can also receive guidance and feedback from their instructors. As more clinical facilities limit access to the EMR, we must become more creative in the way we teach documentation. Using an Academic EMR in the simulation environment is one way to achieve this goal. The trick is to incorporate this tool seamlessly into your teaching.
This may seem like an overwhelming task. By starting small and using an Academic EMR in one area first, instructors and students will have time to get acquainted with the software. Not long ago, students went to the hospital and reviewed the chart the day before clinical. They were expected to complete a worksheet or prep sheet on their patients. This exercise provided critical time for the student to think and process patient care. You can recreate this experience by using an Academic EMR with a one-page worksheet to be completed prior to simulation. Most Academic EMR’s are internet-based so students can access them from home. Assign the worksheet as homework and call it the “ticket to simulation”. The worksheet helps the student by creating familiarity with the patient, diagnosis, and the care necessary. Allowing students to see the chart before simulation decreases anxiety and fosters an environment where knowledge is put into action.
Select one sim where you can use the Academic EMR. You might opt for one of the premade sims or find a current scenario that can be loaded onto the software. Whether you use a current simulation patient or one that is premade, be sure that the information documented in the patient chart is complete and accurate. This is the basis for your worksheet and should paint a clinical picture for your students. As the students use the EMR to complete their worksheet, it will guide them in seeing what information is pertinent. Sample Worksheet
Write It Down
Once the student is in the simulation, there are two ways the instructor can use the EMR. First, simply let the student chart as the simulation progresses. They can use the chart to look at MD orders, see what medications should be given, and know what care they should provide. The student charts exactly like they would in the clinical environment.
The second method is to work with the student as they chart. For a first semester student, this may be best, as they need more guidance. Help them see exactly what should be checked off during assessment, what information needs a narrative note, and how it is important to link care provided with problems listed.
In either method, the student should submit the work to the instructor. Docucare, an Academic EMR, has a submit function. Once turned in, the instructor can review the documentation, make comments, and return the assignment to the student. The student receives feedback, and this closes the loop for learning.
For an instructor, charting provides a glimpse of what the student is thinking and their ability to sort out key points that need to be charted. Helping our students develop good documentation skills while still in school is paramount to their success as nurses. Using an Academic EMR, reviewing student charting, and providing guidance will enhance learning and develop good documentation skills.