This story is part of an ongoing series about the BYU College of Nursing’s Mary Jane Rawlinson Geertsen Nursing Learning Center and the College’s constant efforts to update it.
In the basement of the Spencer W. Kimball Tower, students are training to be observers. All their subjects are kept under intensive watch, with any changes in behavior or well-being quickly typed into computer files. Nothing escapes their notice, or more importantly, their notes.
No, this is not NSA training; these are nursing students using new software, MedAffinity EHR, that helps them practice documenting patient treatment. It’s a system that hopefully will allow students to adjust better to working in a hospital environment where recording patient data on a computer is the norm.
“MedAffinity is electronic documentation, and the way the real world is going is to have an electronic health record,” says Colleen Tingey, supervisor of the Mary Jane Rawlinson Geertsen Nursing Learning Center (NLC). “The world that [students will be] working in is using electronic documentation, and [they] need to figure out how to do it.”
Documentation in nursing is everything, says Tingey. She teaches students that if they don’t document what they did for a patient, then they effectively didn’t do it, leaving them legally vulnerable if there are questions about what they have done to treat patients.
This documentation used to be mainly by hand, but in recent years the trend has been to do it electronically, including in the hospitals where students do their clinicals. That made it necessary to search out a program that could imitate standard documentation software.
After examining many programs over the years, it was decided that MedAffinity was the way to go, but not without some changes.
The program looks just like a typical electronic documentation software that you would find in hospitals. As students complete their labs in the NLC, afterwards (or during) they record what they did on the program. The “patients” they treat and their background information are preloaded by NLC assistant supervisor Kristen Whipple, so students can write about all the different actions they take to treat them.
“Our goal is to make it as real as possible,” Whipple says. In an effort to resemble a typical hospital environment, the NLC now has computers next to patient beds.
MedAffinity is extremely meticulous, in large part thanks to BYU nursing faculty as well as Tingey and Whipple who helped redesign the software to make it more compatible with the nursing program’s requirements. It now covers many more aspects of documentation, with very specific descriptions of treatment and patient reaction.
Another benefit is that this program helps train not only students in the undergraduate registered nurse program, but also those in the graduate nurse practitioner program.
However, Tingey and Whipple stress that the idea of MedAffinity, which is currently employed mainly in the skills labs, is not meant to show students how to use all documentation software, since it can vary throughout the country. “We’re not trying to teach a certain program; we’re teaching principles of documentation,” Tingey says.
Assistant professor Dr. Deborah Himes, who teaches courses involving MedAffinity, sees other benefits in teaching students how to document their work beyond just their legal protection.
“In a sense, learning how to chart well makes you a better nurse because you think about the outcomes you have to chart when you get to the end,” Himes says. “You do a care for a patient, and you go back to chart it, and you can evaluate how it went based on how the patient reacts.”
Implementation has been an intensive labor, but is now moving along relatively smoothly. It requires constant fine-tuning, and always will due to the dynamic nature of the industry. For students, the adaptation from paper to electronic is not always easy, but Tingey believes that it’s a key training for students.
“They’ll be much more prepared to function in the real world,” she says.