Intraoperative EPIC Documentation Surveys& Results When the AIP OR staff recognized a wide variance and voiced disagreement amongst individual and specialty service charting, leadership assumed the responsibility to analytically review and revise unit EPIC Op-Time documentation practices. As a role model nurse, I was presented with the opportunity to assume this responsibility and to collaborate with other nursing professionals for the creation of specific and organized documentation practices standards. This professional partnership facilitated co-authorship of the Teaching Standard: Intraoperative EPIC Documentation tool.
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Research: Documentation Practices via Survey Monkey
When Kristi and I were presented with the opportunity to collaborate and complete this project, we first began by discussing our own documentation practices. Comparing and contrasting our personal practices provided us with a baseline as to the numerous possible conflicts and concerns our peers were addressing. A significant concern both Kristi and myself were previously aware of was the wide variance of documentation practices that were being imparted on newly hired nurses. The lacking expectations and accountability that was being conveyed was confusing new nurses as well as frustrating to seasoned staff and quite possibly precarious to patients. Therefore, Kristi and I elected to survey our peers in two groups to review their Op-Time knowledge base and practices separately. It was determined that selecting the two groups would focus on experience, meaning the staff were selected according to their current practice role, either current/new hire (hired after January 2014 and/or currently orientating) versus seasoned staff (off orientation for 1 year and/or hired before January 2014). The primary goal of methodically selecting these group was to assess nurse practices in relation to OR experience.
While constructing the surveys, Kristi and I centered our questions around "grey areas" of the Op-Time chart. These "grey areas" are sections we believe significant variance in documentation practices occurs related to individual perception and rationale of the primary nurse. As our primary reference, we adopted an online survey tool as means to assess and review the staff's documentation practices. Kristi and I desired that each survey contain the same content as to easily compare and contrast data. We both authored five questions each addressing "grey areas" such as skin assessment, delay rationale, clinician communication, critical events etc. Once complete, Kristi distributed the survey to all current and recent orientee nurses while I distributed the same survey to all remaining nurses including Service Specialists and Charge Nurses. The documents below are the survey questions that were distributed to the staff and directly highlight the inquires I authored and contributed.
While constructing the surveys, Kristi and I centered our questions around "grey areas" of the Op-Time chart. These "grey areas" are sections we believe significant variance in documentation practices occurs related to individual perception and rationale of the primary nurse. As our primary reference, we adopted an online survey tool as means to assess and review the staff's documentation practices. Kristi and I desired that each survey contain the same content as to easily compare and contrast data. We both authored five questions each addressing "grey areas" such as skin assessment, delay rationale, clinician communication, critical events etc. Once complete, Kristi distributed the survey to all current and recent orientee nurses while I distributed the same survey to all remaining nurses including Service Specialists and Charge Nurses. The documents below are the survey questions that were distributed to the staff and directly highlight the inquires I authored and contributed.
aip_or_epic_charting_guidelines_sm_questions_for_final_survey_ss.docx | |
File Size: | 19 kb |
File Type: | docx |
aip_or_epic_charting_guidelines_sm_questions_for_final_survey_o.docx | |
File Size: | 19 kb |
File Type: | docx |
Review: Documentation Practices Survey Monkey Results
The AIP OR EPIC Charting Guidelines Surveys were open and available to staff to complete for 29 days. Over this time, 41 of 115 nurses completed the Service Specialist/Current Staff survey and 19 out of 30 newly hired nurses in 2014 complete the Recent/Current Orientee survey.
Once the surveys were closed, Kristi and I chose to review the results individually. As I distributed the survey addressing seasoned staff including Service Specialist and Charge Nurses, I also chose to reviewed and analyzed this survey's results. Throughout the survey review, I found the data to be conclusive to our initial suggestion; significant variance in rationale and routine documentation practices existed even amongst our seasoned staff nurses. Also during this review, I became aware that our nurses were in desperate need of not only documentation standards to support and guide practice but also in need of a comprehensive reorientation to EPIC, specifically Op-Time and the unique design of the UCH AIP OR intraoperative chart.
The graphs below help to illustrate the data and rationalize the survey results from the AIP OR EPIC Charting Practices Survey that I composed, distributed and reviewed. Please enjoy reviewing each graph to discover the seasoned staff's knowledge of documentation expectations and current documentation practices.
Please select the images to enlarge and/or hover over the images below for more details.
The documents below include the survey key as well as the individual survey results. As previously mentioned, I reviewed and completed the analysis of the Service Specialist and current staff charting practices survey. The graphs above illustrate this data, however the data is also formatted and organized as a document with free text comment responses from the respondents for additional review.
aip_or_epic_charting_survey_key.docx | |
File Size: | 20 kb |
File Type: | docx |
aip_or_epic_charting_guidelines_sm_results_(service_specialist_and_current_staff_charting_practices).docx | |
File Size: | 25 kb |
File Type: | docx |
aip_or_epic_charting_guidelines_sm_results_(current_and_recent_orientees_charting_practices).docx | |
File Size: | 20 kb |
File Type: | docx |
Revise: Documentation Practices Survey Monkey Analysis
After individual review of the survey results, Kristi and I comprised a document comparing and contrasting the data of the two surveys. During this process, it became evident that the two groups had a significantly varied understanding of EPIC Op-Time documentation expectations and practices. Also during this review, Kristi and I exposed an outlet for direct feedback via the free text responses. The staff fully utilized the free text questions to verbalize their comments and concerns with EPIC. They also utilized this outlet to provide recommendations for charting continuity and development of documentation standards. The collaborative document below diagrams the two surveys, providing a visual element to compare and contrast the two surveys side-by-side in graph form.
aip_or_epic_charting_guideline_sm_data_results.docx | |
File Size: | 36 kb |
File Type: | docx |
The construction and review of these surveys served as primary resources in the creation of the Teaching Standard: Intraoperative EPIC Documentation tool. The data and feedback acquired helped to identify important focus areas and supported the suggestion for staff re-education. Both survey results also helped to provide some clarity in the concerning "grey areas" related to individual practices and experience level. The surveys were essential to the development and drafting process of this teaching standard and will remain a valuable resource for future review of this tool.