Journal of Nursing Education

Syllabus Selections: Innovative Learning Activities Free

An Old Concept With New Challenges: An Innovative Approach to Paper Documentation

Matthew J. Fox, MSN, RN-BC

Most facilities are now using an electronic health record (EHR). The EHR provides the bedside nurse with valuable tools to promote patient safety. Technical issues are unavoidable and may lead to an acute care facility EHR to be unavailable. This period of unavailability is commonly referred to as a downtime event. Many new nurses have not experienced documenting patient assessments, documenting medication administration, or transcribing a provider order. New graduate nurses do not know how to complete paper documentation. Simulated clinical experiences can be used to prepare a new nurse to document in a manner that promotes patient safety and communication during a downtime event.

Historically, most faculty have spent years providing care at the bedside without an EHR and other forms of electronic documentation. As a result, faculty may assume that undergraduate students know how to do the same. In many cases, undergraduate students have never seen a handwritten physician order, nor documented patient assessment findings without using a computer at the bedside. The goal of this activity is to provide nursing students with an opportunity to transcribe handwritten provider orders. Illegible provider orders were to be identified and clarified to promote safe patient care.

A classroom-simulated clinical experience was developed based on a patient presenting to the emergency department setting with shortness of breath. As the students were receiving handoff report, an announcement was made that the EHR was unavailable and would not be functioning for several hours and to follow downtime event procedures. The faculty member then explained that all care would be documented using paper and all provider orders would be transcribed and recorded on a paper medication administration record.

As the scenario began, the nursing students were expected to perform a focused assessment on the respiratory system. A faculty member playing the role of a nurse practitioner presented to the bedside and gave the nursing student a verbal order for a breathing treatment and an epinephrine injection. The verbal orders given were accurate and the students read back to confirm. At that time, the nurse practitioner exited the room and left more handwritten orders at the nurse's station. The orders included medications without a route or frequency and were illegible.

After 10 minutes, the patient was stabilized and students proceeded to the nurse's stations. At the station, the handwritten provider orders were reviewed. During this, the students encountered illegible handwritten orders. Seeking clarification from the provider was the next expected action. Students had to telephone the provider to ask for clarification of the orders. The orders were then carried out until the completion of the simulated clinical experience.

At the conclusion of the classroom simulation, students completed a survey. The survey illustrated that students felt there was an improvement in confidence of transcribing handwritten provider orders. One student submitted the following feedback: “[It was] helpful to feel like we are in a real-life situation.” Faculty can incorporate verbal or handwritten orders in simulations to expose students to the concept of handwritten orders to improve patient safety.

Matthew J. Fox, MSN, RN-BC
Ohio University


The author has disclosed no potential conflicts of interest, financial or otherwise.


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