David Michael Miller
The first thing that Kate Trapp, a registered nurse with Agrace HospiceCare, does before walking into a patient’s home is review details of the patient’s recent emergency room visits, lab tests and medications on her laptop. That way, she can keep her laptop in her bag when she greets the patient and respond to any immediate needs, like making the patient comfortable or managing pain.
When she does need to use her laptop to log the patient’s status, she explains why she is taking it out and maintains conversation. “I stay conscious of, ‘Am I staring away from the patient? Am I typing too much?’” Trapp says.
When Beth Strauss was in nursing school 25 years ago, she was trained to talk to patients one-on-one. Now a nursing instructor at Blackhawk Technical College in Janesville, Strauss says today’s nursing students must master a different skill: engaging the patient and updating electronic health records simultaneously.
Electronic health records have radically improved how health care professionals diagnose and treat patients, but documentation requirements have caused a significant, nontechnical glitch. Patients can feel ignored, and care suffers, if nurses and physicians spend the brief time they have in the room fixated on a computer screen.
“Medical education and nursing education is really grappling with: ‘How do we train the health professionals of the future to care for the patient and not for the electronic health records?’” says Katharyn May, a professor and the dean of the UW School of Nursing.
For nurses, that balancing act is toughest when a patient is first admitted and there are several dozen questions — and in some cases, hundreds — that they are required to ask and document.
“To the patient, this process can feel mechanical,” says Kim McPhee, the nurse residency program coordinator at UW Health.
But the answers can have significant impacts on the health care provider’s course of action both immediately and in the future. Questions about a patient’s living arrangements and relationships can determine whether a discharge plan needs to include special accommodations. They are important questions that a nurse wouldn’t know the answers to without asking.
Hannah Dornbusch is a registered nurse in UW Hospital’s Trauma and Life Support Center. When a patient arrives who is responsive but in severe pain, “sometimes it’s a balance between being emotionally supportive and trying to get the questions answered,” she says. Dornbusch tells patients, “I know this is hard, but if you don’t mind, I have to ask you a couple of questions.”
For her doctoral work, Strauss studied patients’ perceptions of nurses using electronic health records. One participant described feeling like an “information bank” that the nurse drew on to answer the computer’s questions. Another participant conveyed disappointment when a nurse entered the room and proceeded to the computer without acknowledging him.
Not surprisingly, Strauss found that patients felt more at ease when nurses greeted them, responded to immediate needs of the patient first, and explained their movements as they accessed and used the electronic health records system.
For nurses just beginning their careers, the volume of charting they must complete can be daunting. Many hospitals have rigorous nurse residency programs in which experienced nurses oversee and coach new nurses, reminding them to face the patient and avoid “nursing the monitor” — while still ensuring thorough documentation.
On Dornbusch’s unit, more experienced nurses help new nurses complete their charting. “We’re focused on being very supportive and helpful when a patient comes in,” she says. “It’s not always possible for one nurse to do all the required charting.”
With experience, young nurses develop a rhythm. May recently observed one in an exam room with a child, who was her patient, and the child’s mother. The nurse told the mother she needed to quickly add what they had just discussed to the child’s record. When she finished typing, she turned back around, made eye contact with the mother, smiled and said, “Okay. I’m caught up, so let’s talk more.”
When it comes to the use of electronic health records, small tweaks like that can easily be incorporated into care to strengthen the nurse’s relationship with the patient, Strauss says.
Detailed records can both personalize experiences and save lives. Records for at-home care can include a patient’s personal preferences, such as a favorite food or type of music so nurses can incorporate these into their visit. In intensive care units, physicians, nurses and pharmacists often view the records remotely, at different times, and rely on the information to make decisions.
“Assessing patient status is always the first priority,” May says. “Documentation is absolutely essential, but documentation is a second-order function.”
