Working in the newborn intensive care unit (NICU) at the University of Utah has allowed me to become proficient with working with different information systems and devices. The use of the Electronic Health Record (EHR) is a main source of information systems within my current setting. I have taken part in evaluating the charting that is available regarding our premature and sick infants and have performed numerous evaluations in order to improve the current systems. The nursing staff have requested many areas be added to the EHR in order to improve the quality of charting for our patient population.
Recently, I was involved in adding a criteria within the EHR. Many nurses within the unit felt as though there needed to be an addition to the EHR regarding the infants stability/lability in regards to oxygen saturation's. The health educator of the unit requested the new criteria: Stable/Labile to be added in our vital signs tab. When this idea was brought forth during a staff meeting, I was extremely hesitant. My concerns in the addition of this new area was that staff members would no longer document desaturations, which is associated with an infant being labile. Many infants drop saturation's down into the low 80's/high 70's. Unfortunately, when a child is dropping down into the 40-60s, I find this more problematic. When we are charting labile without continue charting of desaturations, key changes in the infant's status may be missed! This new area in charting was applied on Friday January 14 and I have already noticed that individuals are not charting the exact desaturation value and simply clicking labile. Based on my assessments of the addition in charting, I do not find it beneficial in trending. This is an excellent example of how I have taken part in implementing, evaluating, and improving the information system within my institution.