HSN/376 Week 2: The Electronic Health Record and Nursing Data, sample paper

What the Labor Record Keeps and What It Loses: Structured Oxytocin Documentation in the Electronic Health Record of a Community Birthing Center

[Student Name]

University of Phoenix

HSN/376: Health Information Technology for Nursing

Week 2 Assignment

[Instructor Name]

[Date]

The birthing center, its record and its audit are a composite written for a model paper.

In Week 1, I followed one oxytocin titration from raw data to a decision and argued that information depends on how consistently nurses record data. This paper looks at the tool that holds those data, the electronic health record on my 12-bed community birthing center, and asks two questions: what does the record keep about oxytocin care, and what does it lose?

How the Record Is Built

Our record gives labor nurses three ways to document oxytocin care. The medication administration record holds each rate change, scanned against the order. The labor flowsheet holds structured rows for contraction frequency, duration, intensity and resting tone, fetal heart rate baseline, variability, accelerations and decelerations, and maternal vital signs, each with fixed choices or number fields. A free-text nursing note holds anything else. The flowsheet also allows a single entry, "within defined limits," for the uterine and fetal assessment, a form of charting by exception.

Structured data are the part of the record that informatics can use. They can be trended on a graph, checked against rules and pulled into reports. Free text can hold the nurse's reasoning, which structured fields cannot, but it cannot easily be counted or searched. According to the American Nurses Association (2022), informatics nurses carry a responsibility to support data that are accurate, standardized and available for decision-making, which in practice means that the fields a nurse fills in are designed for the decisions they must support.

What a Small Audit Found

Our unit's practice council reviewed 30 charts of patients who received oxytocin over two months, looking at the flowsheet entries during the infusion. Three patterns stood out.

First, contraction frequency was recorded as a number in only 19 of the 30 charts; in the other 11, nurses selected "regular" or "every 2 to 3 minutes," which cannot be averaged over a 30-minute window. Without numbers, the record could not show whether tachysystole occurred.

Second, "within defined limits" was used during active titration in 12 charts. The unit's definition of normal did not include contraction frequency at all, so an exception entry could hide exactly the finding that should stop an increase.

Third, when the infusion was paused or reduced, the reason appeared only in free-text notes, written at the end of the shift in 9 of 14 cases. The record therefore held the rate change at the minute it happened but held the reason hours later, in a form no report could find.

Why It Matters for Safety

Oxytocin is a high-alert medication, and the most common path to harm is excessive uterine activity that goes unrecognized or is not acted on (Simpson & Knox, 2009). Each gap in the audit weakens the record's ability to support the nurse at the bedside and the team reviewing care later. A nurse coming on shift cannot see a trend that was never recorded as numbers. A physician reviewing the chart cannot tell whether an increase was safe. And the unit cannot measure whether its protocol is followed, because the data needed to check it are not structured.

Evidence shows that structure itself can change care. Clark et al. (2007) reviewed the charts of the last 100 women given oxytocin under the old approach and the first 100 under a new one, in which nurses had to confirm specific maternal and fetal criteria before each increase. The maximum infusion rate fell from a mean of 13.8 to 11.4 milliunits per minute, the time from infusion to birth did not change, and the number of newborns with any adverse outcome index fell from 31 to 18. A checklist is a structured data tool: it forces the nurse to record the specific findings that justify each decision.

Proposed Changes

Based on the audit and the evidence, the practice council proposed four changes to the record.

1. Make contraction frequency a required numeric field during oxytocin infusion, with the flowsheet displaying the 30-minute average automatically.

2. Remove "within defined limits" as an option for the uterine assessment while oxytocin is running, so that the key findings must be entered individually.

3. Add a structured checklist, completed before each rate increase, confirming the criteria in the unit's protocol, modeled on the approach Clark et al. (2007) reported.

4. Add a required reason field, with fixed choices such as tachysystole, fetal heart rate pattern or maternal request, whenever the rate is decreased or the infusion is stopped.

Who Uses These Data, and When

The value of structured oxytocin data becomes clearer when one follows who reads them. At the bedside, the laboring patient's own nurse uses the trend to decide whether the next increase is safe. At shift change, the oncoming nurse uses the same trend to understand an infusion she did not start. During labor, the charge nurse scans the unit's central display and flowsheets to decide where help is needed. After birth, the obstetric quality committee reviews cases with poor outcomes, and risk managers read the record if a family raises a concern. Months later, the unit's educator uses aggregated data to see whether the protocol is followed. Each of these readers needs the same few facts, the contraction count, the fetal heart rate pattern and the reason for each rate change, and each is served poorly by words like "regular" or by a note written at the end of the shift. Designing fields for those readers is a nursing informatics task, because nurses are the ones who know what the readers need.

Costs and Unintended Consequences

Every added field takes time, and nurses already spend much of a shift documenting. The council estimated that the checklist would add about one minute per rate increase, which is small compared with the time spent reconstructing a titration from notes after an adverse event. Required fields can also produce automatic answers entered without thought, so the checklist would be reviewed in chart audits after three months. Changes to the record need approval from the hospital's clinical informatics committee and the obstetric department, and nurses would need training before go-live.

Conclusion

The electronic record on my unit kept the medication data about oxytocin well and lost the nursing data that explain it. Numbers were recorded as words, normal was defined without the key finding, and reasons were written too late to be used. Structured fields, a pre-increase checklist and a required reason field would make the record support safety rather than simply store it. Week 3 turns to clinical decision support, the part of the record designed to help nurses decide.

References

American Nurses Association. (2022). Nursing informatics: Scope and standards of practice (3rd ed.).

Clark, S., Belfort, M., Saade, G., Hankins, G., Miller, D., Frye, D., & Meyers, J. (2007). Implementation of a conservative checklist-based protocol for oxytocin administration: Maternal and newborn outcomes. American Journal of Obstetrics and Gynecology, 197(5), 480.e1-480.e5. https://doi.org/10.1016/j.ajog.2007.08.026

Simpson, K. R., & Knox, G. E. (2009). Oxytocin as a high-alert medication: Implications for perinatal patient safety. MCN: The American Journal of Maternal/Child Nursing, 34(1), 8-15. https://doi.org/10.1097/01.NMC.0000343859.62828.ee