1 Capstone Project Review Angela McNutt NURS 4873: Capstone for Career Advancement University of Central Oklahoma Dr. Wilson November 14, 2021 2 Capstone Project Review The current paper charting system at the Community Health Clinic (CHC) is disorganized, particularly in an area where these medical records are awaiting review of labs or medication orders. This cluttered space presents concerning issues that could lead to ineffective communication between clinicians, potential leaks in protected health information (PHI) due to misplaced documents, and other challenges surrounding a paper record system. This essay will further describe the impact of this problem and the best strategy for its resolution based on supporting research. Problem Statement The quality improvement topic is centered on the current paper charting system. Issues pertaining to the arrangement of the paper-based medical records allows for miscommunication among team members, insecure PHI, and documentation errors. Many developed countries like the United States (U.S.) continue to document on paper, despite evidence-based research that illustrates the disadvantages associated with paper charting (Muinga et al., 2021). At the CHC, it’s apparent that during a clinical work day, patient charts are disorganized. The area where charts are awaiting review of labs and medication orders, is located in the nurse’s station. These folders are often scattered and in disarray, which can ultimately contribute to many problems that impact patient care. A few roles within the interdisciplinary team contribute to the disorganization of the paper-based medical records, which negatively affects the patients. Both nurses and physicians place charts in this area. If these folders are not separated into distinct piles, the wrong patients may receive lab or medication orders that aren’t needed. Another problem that contributes to the disorganization within this space is that paper medical records don’t allow for multiple people to 3 use the chart simultaneously. A chart may need an order for medication or that labs need to be reviewed but if a nurse or other clinician is accessing the chart, the patient may be overlooked because the folder is not where it’s supposed to be. It’s the patients who would benefit from the improvements made towards establishing a more regulated paper-based medical record system. If the issue is not addressed, it could inadvertently cause harm to the patient because miscommunication is a product of disorganization, which can lead to safety problems such as unnecessary treatment interventions. HIPAA violations are also concerning because when charts are poorly handled, important medical documents can easily fall out and be lost or misplaced. Assembling a desk organizer in the space will help to create distinct sections for charts awaiting labs or medication orders, and will assist with maintaining documents in their folders because the charts will be arranged in a way that decreases the likelihood of important documents to fall out. Strategy Inspired by observational data and credible resources, organization of the area where charts are awaiting review of lab or medication orders would facilitate a more effective way to manage the paper-based medical records. The best strategy to resolve clutter in this storage space is to have separate file holders for the patient folders. Having a desk organizer to keep the charts separated will reduce the chance of folders mingling into the wrong pile, such as the section for reviewing labs or pending medication orders. The foundation for the development of this quality improvement design is based on the many studies that indicate the flaws that are associated with the use of paper-based medical records. 4 Strategy and Supporting Evidence Volunteering at the McKinney Community Health Clinic presents the opportunity to better arrange their paper chart system while they work to transition into using an electronic medical record (EMR). Focusing on this small area allows for a more concise perspective and concentrated observational data to compare progress rather than obtaining differing opinions about patient chart storage spaces throughout the clinic. To begin this research project, the two file holders are to be assembled where the charts are awaiting lab reviews and medication orders. Each organizer has seven large slots for folders to be placed. One holder will be arranged in the section labeled charts for lab review, and one will be placed in the section labeled charts for medication orders. All staff such as the receptionist, nurses, and physicians will be briefed about the new organizational method and its intended use. Approximately one month later staff will be given a survey to obtain qualitative data, which will ultimately determine how well this strategy improved communication amongst team members and how it decreased the risk of misplaced patient documents. Contributing factors to paper-chart disorganization include lack of time, too many patient documents, and the inability for multiple clinicians to use the chart simultaneously. An EMR has been shown to decrease the amount of documentation needed and improve time efficiency compared to a paper-based medical record system (Coffey et al., 2015). Another study found that unlike paper charting, the increased availability for multiple providers to access the EMR system enhances quality of care and patient outcomes (Ayaad et al., 2019). In conclusion, the disorganization and inadequacy of paper-based medical records is evident in the literature, which justifies the need for a better way to arrange the paper charts to reduce clutter and promote a more efficient work environment. 5 Research from credible resources confirms that maintaining paper-based medical records poses security challenges for PHI. A qualitative study interviewed healthcare staff about their perceptions of paper and electronic documentation. Interestingly, participants voiced distrust about the privacy of paper-based medical records. Clinicians explained that they would refuse to be cared for at their own facility because of how easy it is for unauthorized staff to access patient charts when using a paper-based method (Saito et al., 2017). Furthermore, another analysis conducted throughout a hospital found that paper records were frequently left unattended. This was especially true in the nursing stations, which raises concern about the privacy of patient information when using this kind of medical record system (Lambe et al., 2018). By arranging the file holders in an area that’s more likely to have unsecured PHI, such as the nurse’s station, this should keep patient folders organized and prevent charts from being scattered. The expected outcome of this strategy is to keep important patient documents placed neatly in their respective charts and build enhanced communication amongst clinicians. This benefits all staff members by promoting teamwork, which can improve the quality of care that’s being rendered by preventing unsafe events and generating a more efficient environment. Subsequently with these changes in place, a leak in PHI is less likely. Conclusion It’s clear that the disorganization of the paper records, which are kept in the area where charts are awaiting review of labs and medication orders, can lead to many issues involving the quality of patient care. The goal of establishing a file holder is to reduce clutter and keep the patient folders in their designated space. This will help to minimize the problems associated with using a paper-based medical record system while the CHC works to transition into utilizing an EMR. 6 References Ayaad, O., Alloubani, A., Alhajaa, E. A., Farhan, M., Abuseif, S., Al Hroub, A., & AkhuZaheya, L. (2019). The role of electronic medical records in improving the quality of health care services: Comparative study. International Journal of Medical Informatics (Shannon, Ireland), 127, 63–67. https://doi.org/10.1016/j.ijmedinf.2019.04.014 Coffey, C., Wurster, L. A., Groner, J., Hoffman, J., Hendren, V., Nuss, K., Haley, K., Gerberick, J., Malehorn, B., & Covert, J. (2015). A comparison of paper documentation to electronic documentation for trauma resuscitations at a level I pediatric trauma center. Journal of Emergency Nursing, 41(1), 52–56. https://doi.org/10.1016/j.jen.2014.04.010 Lambe, G., Linnane, N., Callanan, I., & Butler, M. W. (2018). Cleaning up the paper trail – our clinical notes in open view. International Journal of Health Care Quality Assurance, 31(3), 228–236. https://doi.org/10.1108/IJHCQA-09-2016-0126 Muinga, N., Abejirinde, I. O. O., Paton, C., English, M., & Zweekhorst, M. (2021). Designing paper‐based records to improve the quality of nursing documentation in hospitals: A scoping review. Journal of Clinical Nursing, 30(1-2), 56–71. https://doi.org/10.1111/jocn.15545 Saito, K., Shofer, F. S., Saberi, P., & Green-McKenzie, J. (2017). Health care personnel perception of the privacy of electronic health records. Journal of Occupational and Environmental Medicine, 59(6), 535–538. https://doi.org/10.1097/JOM.0000000000001016
