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Laura Martin, LPN
Laura Martin, LPN, at a Workstation on Wheels (WoW). These workstations are used for clinical documentation on the go.

Electronic charting of patient behaviour improves quality for patient and care teams

Dealing with an agitated patient kicked off some valuable insights for LPN Laura Martin, who learned how the electronic health record can follow patients wherever they interact with health services, and make a difference in plans for their care.

On her second shift in Surgical Day Care following the launch of electronic clinical documentation, Laura was trying to care for a difficult patient in the recovery area. “She wanted to leave immediately but we have protocols we have to follow,” says Laura, “And she didn’t yet meet any of them. Because we had other patients, it was really important just to keep her calm. So it was decided that she could be discharged AMA [against medical advice].”

Charting behaviour events with the EHR

Laura made notes to prepare for charting later in her shift, and was nervous about using the EHR for this more complex case. Noticing that Home and Community was also in contact with the patient for wound care, she wasn’t sure she would be able to use the new system to capture all the details and let the community nurses know what had happened.

“I thought ‘How I am I going to chart all of this? This is going to be enormous! This is frightening!’ So I kept delaying it.”

After caring for her next few patients, Laura opened the EHR and started to document her interaction with the discharged patient. Now focused on the behaviours she observed, Laura opened the violence risk assessment.

“Based on the way I answered it, it automatically took me to the VBACT [violent behaviours assessment considerations tool]. And I had no idea that was going to happen. Even though I had done the training, it’s different actually doing it in person. As soon as it opened, it was like an ‘aha moment’. ‘Oh that’s where I can do all of my documentation!’”

Thanks from Home and Community

“The end result was the next day I was at work, and the phone rang and the unit clerk said ‘Laura, there’s somebody that wants to talk to you.’ I took the call and it was the Home and Community nurse. She said ‘Is this the nurse that discharged Patient X?’ I said ‘Yes,’ and she said ‘I was just phoning to say thank you, because you updated the VBACT on the computer and as a result of that there have been some significant changes on our end’.” Having a VBACT for the patient prompted the community care team to do a daily check before visiting the patient, with the option of escalation based on the patient’s further behaviour with the community team.

Laura was struck by how a tool like the EHR has impacts beyond immediate patient treatment in acute care, and affects what happens when the patient leaves the hospital, as well. She notes that it’s not only better for the patients, but also improves the likelihood of safety for the nurses.

“I was telling other nurses about how wonderful it is, and how the changes to Clin Doc are going to benefit the patients and the bigger picture.”

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