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Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports

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  • Krystle Martin
  • Elke Ham
  • N Zoe Hilton

Abstract

Aims and objectives To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process. Background The ability to accurately document patients’ symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544–1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544–1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122–1131). Design The project was a mixed‐method, two‐phase study that collected data from two sites. Methods In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice. Results Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration. Conclusions We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation. Relevance to clinical practice Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases.

Suggested Citation

  • Krystle Martin & Elke Ham & N Zoe Hilton, 2018. "Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports," Journal of Clinical Nursing, John Wiley & Sons, vol. 27(15-16), pages 3171-3178, August.
  • Handle: RePEc:wly:jocnur:v:27:y:2018:i:15-16:p:3171-3178
    DOI: 10.1111/jocn.14511
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    1. Febe Friberg & Anne‐Louise Bergh & Margret Lepp, 2006. "In search of details of patient teaching in nursing documentation – an analysis of patient records in a medical ward in Sweden," Journal of Clinical Nursing, John Wiley & Sons, vol. 15(12), pages 1550-1558, December.
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    1. Krystle Martin & Rosemary Ricciardelli & Itiel Dror, 2020. "How forensic mental health nurses’ perspectives of their patients can bias healthcare: A qualitative review of nursing documentation," Journal of Clinical Nursing, John Wiley & Sons, vol. 29(13-14), pages 2482-2494, July.

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