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Nursing Documentation in a Mature EHR System
Abstract
Computerized patient care documentation (CPD) is a vital part of a Patient Care Information System (PCIS). Studying CPD in a well-established PCIS is useful because problems of system adoption and startup do not interfere with observations. Factors interfering with optimal nursing use of CPD areparticularly challenging and of great concern, given today’s shortage of nursing manpower. We describe problems and advantages of CPD usage identified by nurses in a series of research interviews. The chief advantages of CPD for nurses found were better accessibility and reliability of patient care documentation. The main disadvantage was an awkward fit between current input technology and nursing workflow. A second disadvantage was difficulty in translating portrayal of the nursing process into readable documentation that is useful to all members of the clinical team. We interpret these findings to show that explicit consideration of nursing workflow constraints and communication processes is necessary for development of effective nursing documentation systems. Some findings point to a PCIS reconfiguration strategy that is feasible in the short term. Other findings suggest the value of considering mobile and team-oriented technologies in future versions of the PCIS.
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