Documentation of Patient Information and Medication Safety in Nursing Practice

This review examines the role of documentation of patient information in medication safety under clinical practice. The review highlights the importance of health information technology in improving the documentation process and the level of patient medication safety. The relevance of clinical practice includes effective training of nursing professionals to efficiently handle the documentation process while providing care to the patient.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Introduction
In nursing, the process of documentation is defined as a comprehensive, sequential
and factual record of the patient’s health related condition, treatment plan and the support
offered. Failure in proper documentation in the patient’s data or clinical history or the therapy
plan might lead to fatal outcomes (Blair & Smith, 2012). Medication errors are a problem in
Australia. Medication errors occur for a number of reasons like human errors and other
factors like how the medicines are prescribed, dispensed or administered to the patient. The
majority of the medication errors in Australia occur as a result of error in the documentation
process leading to increase in the mortality and morbidity of the patients (ACSQHC, 2017).
In order to improve the healthcare outcomes by decreasing the morbidity and
mortality in healthcare, the Australian Commission on Safety and Quality in Health Care
(ACSQHC) has introduced National Safety and Quality Health Service Standards (NSQHS)
in 2012. The standard 4 of the NSQHS outlines the medication safety standard to decrease
the occurrence of medication incidents, and to improve the safety quotient in health and
quality of medicine use (ACSQHC, National Safety and Quality Health Service Standards,
2012). The aim of this review is to examine the role of the documentation of the patient’s
information in the domain of medication safety under clinical practice. At the end the review
will highlight the main implications of the clinical practice. The overall review will be
conducted based on the available literature on that coincides with the scope of this review.
Background
The quality of documentation of the patient’s information is an important issue for
nursing professionals working nationally and internationally (Blair & Smith, 2012). The
documentation of the patient’s information by the clinical workforce deals with accurate

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documentation of the medication history during the process of the patient’s prognosis. It also
encompass documenting the previous patient’s history in relation to the adverse drug
reactions and reviewing the current medication orders against the medication history and
highlighting any discrepancy in the medication plan (ACSQHC, National Safety and Quality
Health Service Standards, 2012). Nursing documentation must, but frequently fail to
highlight critical thinking and rational behind the clinical decision making and interventions
while submitting the written documentation of patient’s prognosis. The gap in the critical
thinking and lack of evidence-based practice leads to improper documentation of the patient’s
health-related information and thereby endangering the concept of the medication safety
(Blair & Smith, 2012). Apart from the lack of critical thinking and problem solving skills, the
increase in the work-pressure or poor nurse : patient ratio in the high-tension ward like the
emergency department or in the ICU leads to the error in the process of the nursing
documentation and creating a barrier in comprehensive implementation of the medication
safety procedure (Hall, Johnson, Watt, Tsipa, & O’Connor, 2016). Thus in order to improve
the medication safety the healthcare industry of Australian healthcare system is spending
surpasses for the adoption of the health information technology (HIT) for proper
documentation of the patient’s information (Schoen, et al., 2012). HIT products like
electronic health records (EHR) and computerised physicians’ based order entry (CPOE)
have now become more intimately involved in delivering comprehensive care by ensuring
medication safety (Lainer, Mann, & Sönnichsen, 2013).
Review of literature
Numerous studies were analysed as part of conducting the literature review. All
authentic yet relevant findings were then classified under three different themes which
evolved as the significant outcome of the review. These three themes include nursing

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documentation by the use of Healthcare Information Technology, Use of COPE in ensuring
patients’ medication safety and privacy and confidentiality issue associated with
documentation of patients information in IHT medium.
Nursing Documentation by the use of Health Information Technology
There is a prolong debate regarding whether the application of the health information
technology is helpful in improving the process of medication safety by increasing the quality
of documentation of the patient’s information. A systematic review was conducted over
randomised control trials by two-reviewers in order to study the effectiveness of information
technology (IT) in ensuring medication safety in the primary care. 5 out of the 10 articles in
the review highlighted that the incorporation of the IT for the documentation of the patients’
information helps in to reduce the chances of the medication errors. Three out of the 10
articles showed that the documentation of the patient’s information through COPE with CDS
(clinical decision support system) was found to be effective for ensuring medication safety
only if targeted at a restricted number of the clinically improper medications or unsafe
prescribing in pregnancy. However, the review highlighted on potential reduction in the
adverse drug effects under the application of the IT-based approach for the documentation of
the patient’s information. At the end, the review stressed about the requirement of the
rigorous evaluation of the large-scale implementation of the IT in order to evaluate the
importance of the nursing documentation in medication safety (Lainer, Mann, & Sönnichsen,
2013). In relation to documentation of the patient’s information and to ensure medication
safety, a focus group interview was conducted over the 21-registered nursing professionals.
The analysis of the survey results highlighted that nurses electronic health records is widely
used by the nursing professionals as the principal method for the nursing documentation
process for ensuring medication safety. However, nurses reported that electronic patient’s
record fails to support nursing practice while documenting important health-related

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information of the patient like the vital signs (Stevenson & Nilsson, 2012). The cluster
randomized trail study highlighted the that the personal health record (PHR) –linked
medications module when used in concordance between the documented and patient’s
reported medication regimens is helpful in reducing the potentially harmful medication
discrepancies (Schnipper, et al., 2012). Thus overall it can be said the documentation of the
patient’s information is helpful in ensuring patient’s safety by reducing the chances of the
medical errors or however, proper modifications in the technology must be undertaken based
on nursing opinions in order to make the online documentation process stringent for
recording of the patient’s vital signs (Stevenson & Nilsson, 2012).
Use of CPOE and ensuring medication safety
In the domain of documentation of the patient’s information, computerised physicians
based order entry (CPOE) also holds prime importance. The systematic review conducted in
order to test effectiveness of COPE under the clinical practice highlighted that there are
tangible benefits associated with COPE in order to support clinical practice under emergency
practice. However, study also revealed that potential importance of COPE in medication
safety is neither consistent nor comprehensive (Georgiou, et al., 2013). However, an
observational study conducted for over 6-years highlighted the blessings of the COPE in
ensuring medication safety. COPE is installed with special alert such when after the process
of the medication documentation, whenever wrong medicine is administered the system gives
alert based on the data fetch from the pharmacy order to date or time of medication
administration. This helped to reduce the chances of the medication errors and thereby
helping to improve the patient’s outcome (Galanter, Falck, Burns, Laragh, & Lambert, 2013).
Another restrospective observational study also highlighted similar results. The study
highlighted that use of COPE for documentation of the patient’s medication information
helps to reduce the chances of the medication error arising from the confusion between

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similar drug names. The error interception was determined by the use of an algorithm in order
to indentify the rate at which the alert is triggered (Galanter, et al., 2014). Thus it can be said
that effective documentation of the patient’s medication information through COPE helps to
increase the quotient of the medication safety like EHRs. However, the alters given by the
COPE system at times creates irritation among the nursing professionals. The nursing
professionals vouched for more sophisticated altering strategy that is less interruptive (Jung
& Lawton, 2013). The nursing professionals also reported that the documenting of the
patients medical records increases the clerical job pressure over the nursing professionals
therefore increasing the chances of the job burnout (Nguyen, Bellucci, & Nguyen, 2014).
Privacy and Confidentiality Issues in Patient’s Information Documentation
The main challenges in accessing the EHR usability mainly entails under the
complexity of the EHR interaction under socio-technical context, the defined professional
roles of the intended nursing professionals who are the potential users (Zarcadoolas &
Rockoff, 2013). The other concerns include peculiarities of clinical collaboration patterns and
difficulty in measuring the potential influence that system exerts on the downstream
processes (Meeks, Smith, Taylor, Sittig, Scott, & Singh, 2014). The numerous studies have
highlighted that the documentation of the patient’s information under the use of the EHRs or
through the CPOE at times leads to the breaching of the privacy and confidentiality
(AbuKhousa, Mohamed, & Al-Jaroodi, 2012) (Jardim, 2013). According to the professional
code of conduct by the Nursing and the Midwifery Board of Australia (NMBA), it is the duty
of the nursing professionals ensures privacy and confidentiality of the patient’s information.
However, since EHRs is accessible online, the issues in ethical issues of privacy come at
stake (Hoffman & Podgurski, 2012). However, the issues concerning the privacy and
confidentiality of the patients’ information can be effectively handled under the proper
intervention of the multidisciplinary teams. For example, training of the nursing professionals

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under the doctors for the operation of the EHRS and increasing the stringency of the
algorithm of the EHRs and CPOPE will help to secure privacy of the software operation (Van
Liew, 2012).
Relevance to clinical practice
The review highlighted the importance of the health information technology in
bringing change in the documentation process and thereby helping to improve the level of
patient’s medication safety. However, the review also highlighted that nursing professionals
are of the opinion that their recommendations must be taken under consideration while
designing the guidelines and the protocols of the EHRs and CPOE. Review of literature also
highlighted that the nursing professionals are required to be trained in order to get them
accustomed with the process of documentation of the patients’ information in the IHT. Thus
relevance or implications of the clinical practice include effective training of the nursing
professionals to efficiently handle both the documentation process while providing care to the
patient. Numerous study have highlighted the importance of the reconfiguration of the
nursing workforce through proper education and training in order to increase the overall
quality of care delivery by ensuring the medication safety (Ricketts & Fraher, 2013). Increase
in the skills of the nursing professionals in effectively handling the documentation process
under the application of the IHT and at the same time applying critical thinking for the
nursing diagnosis will help to increase the quality of care (Gagnon, et al., 2012). The process
of effective documentation will also help to reduce the chances of the medication error and
encountering adverse drug effect. The studies have highlighted that such educational and
training campaigns must be framed under the active supervision of the doctors and the
information technology professionals. Lastly it can be said that nursing professionals must
execute effective communication in order to take help from the multidisciplinary team to

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improve their skills in the process of documentation of the patients’ information for ensuring
medication safety (Van Liew, 2012).
Conclusion
Thus from the above discussion it can be concluded that, the process of
documentation of the patient’s information for the improvement of medication safety is an
importance aspect of the Australian healthcare system as highlighted by the National Safety
and Quality Health Service Standards (NSQHS). The technological advancement in the
healthcare domains has introduced the use of the health information technology of the
effective documentation of the patient’s records. Two of the IHT tools that has evolved in this
literature review include EHRs and CPOE. Both the tools have been found to be an effective
medium for ensuring medication safety by allowing effective documentation of the patients
medication management plan. CPOE on the other hand prove to be effective to avoid
confusion arising from similar sounding drugs by giving alerts. However, the application of
IHT in the process of documentation is criticised for being a lengthy process as the nurse fell
that the job is clerical and thereby increasing the job stress. Moreover, the concerns of
breaching privacy and confidently are arise in the domain of using IHT for the
documentation. Moreover, nurses are of the opinion that there are no specific modules for
documenting patients’ vital signs in EHRs creating a problem in documenting patients; heath
history. Thus further improvement in stringency of IHT is recommended along with the
training of the nursing professionals under the guidance of the IT professionals.

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