Running Head: BEDSIDE SHIFT REPORT AND UTILIZING THE EHR

Bedside Shift Report and Utilizing the EHR

Nicole M. Toohey

Delaware Technical Community College

BEDSIDE SHIFT REPORT AND UTILIZING THE EHR

Bedside Shift Report and Utilizing the EHR

Just as the world we live in today has changed because of technology, so too has nursing.

Nursing, at its core, has not changed, but it looks drastically different than it did even ten to

twenty years ago. Technology has changed the face of everything in this world and nursing is no

exception.

Many hospitals and facilities have began using an electronic health record or EHR.

Affinity Medical Center in Ohio began using the Cerner EHR in 2014 (DeMoro, 2014). When

RN’s were asked to comment on the implementation and how it is affecting their time

management they did not hesitate to state how unhappy they were with the new EHR system.

“…nurses are regularly pulled away from patients for the computers, required to devote from 60

to 75 percent of their time at the bedside entering and responding to computer data. Patients in

critical care units may need to have new data typed in every two or three minutes, making it

virtually impossible for the RN to continually monitor very ill patients” (DeMoro, 2014, para.

14). So, the transition to documenting from paper charting to electronic charting can be difficult

and feel as if it is taking precious time away from patients; however, in this digital age it is

important to realize that the EHR are here to stay.

As nurses, working in a world where electronic health records (EHR) are utilized every

day, it is our responsibility to know how to access the EHR, understand the information in it,

properly document patient assessments and nursing notes in the EHR, and be able to extrapolate

information about the patient that may be a safety issue or concern.

A large community hospital implemented the electronic health record software program

EPIC (Epic Systems Corporation; Verona, WI) in September of 2012. By 2014, one of the units

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in that hospital had seen a need for standardizing documentation by the nurses. “Four North is a

30-bed medical-surgical unit that provides care for patients age 18 and older. A unit specific

project was initiated to standardize documentation to make it easier to identify and evaluate

specific patient information and assessments in the EHR” (Elliott, et. al., 2018, p 32). The fact

that there are many different areas to document the same information in this specific EHR

software, means there are possibilities of missing vital information if it is not documented

properly. Another concern is the assessments being charted by nurses in EPIC. While some

nurses would use the option WNL (within normal limits), others would choose to document

further even if the assessment of the area was, in fact, WNL. Over or under documentation can

lead to missed information or information overload.

Four North conducted this study over a three-month period of April-June in 2014. Thirty

patient medical records were pulled and reviewed to compare information that was charted by

nurses. It was found that “employees did not know where to chart, did not know that they

needed to chart, or simply forgot to chart the information” (Elliott, et. al., 2018, p 33). There is a

serious risk to patients and the treatment decisions that are made when charting is incomplete,

incorrect, or hard to find. After the study was conducted, classes and education were provided to

all nursing and nursing assistant staff members. Everyone was educated on expectations for

charting to standardize every patient’s medical record. It was believed that a standardized

patient assessment helps to give a clearer picture of the patient in question. “Standardized

documentation helped to construct a comprehensive picture of the patient that could be reviewed

by unit staff and other healthcare providers” (Elliott, et. al., 2018, p 36).

After the nurses on Four North had time to become accustomed to the expectations of

their patient charting, a new audit was conducted of patient charts. The audit found a significant

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increase in compliance by nurses and CNA’s in every category being audited. Patient records

were easier to read and comprehend by all healthcare providers. A patient chart that is easier to

read and understand leads to less confusion and possible mistakes. “Electronic health record

(EHR) adoption by US hospitals has been increasing with up to 96.9% of hospitals employing a

certified EHR. While there were many purported benefits of this technology, its application has

also fostered significant unintended consequences, a term coined “e-iatrogenesis”” (Sakata, et.

al., 2016, p 636).

As nurses we know to do no harm (nonmaleficence), to always be honest (fidelity) and tell the

truth (veracity), and to do what is best for the individual (beneficence). However, if we do not

take the time to properly learn and understand the EHR that we are working with this can lead to

possible harm of the patient. Every system has its limitations and an EHR software program is

no exception; but to provide the best patient outcomes we need to find ways to overcome those

limitations and provide the best documentation possible so that we can avoid potential problems

in the future.

Another important reason for learning and utilizing the EHR is for bedside shift report.

Shift change can be a hectic time and more facilities are moving to bedside shift report. An

article titled Guide to Patient and Family Engagement in Hospital Quality and Safety noted that

“Research shows that when patients are engaged in their health care, it can lead to measurable

improvements in safety and quality” (as cited in Beattie, 2016, para 2). As important as it is to

have patients and their families involved in the shift change process and the information relayed

there, it is just as important that the nurses are relaying the proper information for the proper

patient. The best way to communicate all the proper information on each patient is to utilize the

computer and the EHR during shift change and bedside shift report.

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The Epic EHR software has a unique way of giving a snapshot of a patient on the main

page of the patient’s profile. The summary page of a patient’s profile in EPIC truly is a snapshot

of the patient and their medical information. It is vital that during shift change bedside report

both nurses view the summary page in Epic to have a better idea of the patient, their diagnoses,

consults, labs, diagnostic images, any new orders to be seen, and any other information that is

necessary for shift change. A brief view of what a bedside shift report would look like utilizing

the Epic EHR follows:

The off going nurse opens the patient’s EHR record in the computer, at the bedside.

The nurse runs through the top of the summary page with me, “This is Mr. John Smith, an

85-year-old full code gentleman. He has no known allergies and you’ll see that Dr. Ahmed

is his attending physician.” Just underneath that information on the summary page is a

section showing orders to be acknowledged and I notice there are some medication orders

that haven’t been acknowledged yet. I ask the day shift nurse if she has seen these. We

look at them together and realize that Dr. Ahmed has made a few changes to Mr. Smith’s

blood pressure medication. This is valuable information to have during shift change. We

discuss it with the patient.

The next section shows any outstanding specimens that need to be collected. I see

that a urine has not been collected during the day shift. The nurse explains to me that Mr.

Smith had been incontinent earlier, and that specimen was unable to be retrieved during

day shift. I make a note about the urinalysis that needs to be done, but I have an

understanding that the day shift nurse did not ignore this task, rather she was unable to

complete it.

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The section below this consists of three things: medical problems including

historical and current, the treatment team on the service of the patient, and any sticky notes

that have been written to the doctor or other members of the treatment team. Now is when

the day shift nurse begins to tell me the story of what brought the patient in. I can see the

medical problems the patient is currently experiencing along with their history. As she is

talking about the consults the patient has I can confirm this with the treatment team section

and if any doctors do not appear in this section, she and I can address that right now.

After we discuss the treatment team and the backstory of the patient we can move on to

their current status such as their most recent vital signs, lab results, imaging results, their

active lines such as IV’s or central lines, their active tubes or drains like a foley catheter,

rectal tube, or chest tubes, and the medications they are one.

After we finish looking at the summary page we can discuss their body systems

such as heart rhythm, lung sounds, mobility, recent bowel movements, etc. Finally, we

will talk about the discharge plans for the patient. Do they live at home alone or with a

support system? Is physical therapy recommending home PT or possibly a rehab for a few

weeks before going home?

Now is when we both look to the patient and ask him if he has any questions or

concerns about what we have discussed. We also ask him if there is anything we can do to

make him comfortable before moving on to the next patient.

Above is an example of a proper bedside shift report. The report involved all parties

including both nurses, the patient, and any family members presents. It also, most importantly,

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involved the use of the EHR and all the vital patient information so that the oncoming nurse was

able to go in to the shift well prepared and fully informed on the patient.

The digital world has changed the way we look at things and electronic health records are

no exception to that. Gone is the day of paper charting and shift report happening at the nurse’s

station. We are nursing in a world that requires technology and navigating it is our responsibility

in order for us to be the best nurses possible for our patients.

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POLICY NMT1100.11

Purpose / Statement: The purpose of this policy is to provide a framework for effective

communication during bedside shift report.

1. Policy Statement

1.1 The Summary page in the Epic EHR will be utilized at every bedside shift report

in order to allow for effective communication during handoff.

1.1.1 Off-going nurse accesses computer at bedside with on-coming nurse.

1.1.2 Patient EHR is opened up to the Summary Page.

1.1.3 Patient demographics are discussed (Name, Age, Code Status, Allergies)

1.1.4 All new orders appearing at top of screen will be discussed between both

nurses.

1.1.5 Outstanding specimen collection is discussed.

1.1.6 Medical problem list discussed including history of medical problems and all

current medical issues.

1.1.7 Treatment team is looked over including all consultations.

1.1.8 Vital signs for last 24 hours are reviewed. At this time nurses discuss the

trend of vital signs.

1.1.9 All active lines, tubes, and drains are reviewed (IV’s, Central Lines, etc.)

1.1.10 Labs and imaging over last 72 hours are reviewed and discussed with patient.

1.1.11 All current medications reviewed.

1.1.12 Review of body systems is discussed between nurses

1.1.13 Patient is informed that bedside shift report is complete and patient’s needs

and concerns are addressed at this time.

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References

Beattie, P. (2016). Bedside Shift Report -- A GAME CHANGER for Nurses and the Patient

Experience. New Mexico Nurse, 61(4), 7.

DeMoro, R. (2014). Questioning the value of electronic health records. National Nurse, 110(4),

11.

Elliott, L., Weil, J., Dykstra, E., Calinski, R., Schurman, J., & Conn, L. (2018, January 1).

Standardizing Documentation: A Place for Everything. MedSurg Nursing.

Sakata, K. K., Stephenson, L. S., Mulanax, A., Bierman, J., Mcgrath, K., Scholl, G., . . . Gold, J.

A. (2016). Professional and interprofessional differences in electronic health records use

and recognition of safety issues in critically ill patients. Journal of Interprofessional

Care, 30(5), 636-642. doi:10.1080/13561820.2016.1193479