Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care

Abstract

The majority of U.S. hospital care units currently use paper-based nursing documentation to exchange patient information for quality care. However, by 2014, all U.S. hospitals are expected to use electronic nursing documentation on patient care units, with the anticipated benefit of improved quality. However, the extent to which electronic nursing documentation improves the quality of care to hospitalized patients remains unknown, in part due to the lack of effective comparisons with paper-based nursing documentation.

Opportunities for nurses in the era of electronic health records

“…Nurses collect the greatest volume of data about the patient and then must communicate the data through information sources for the benefit of the other health care professionals who depend on the information to deliver care [15]. Yet, how nurses exchange information to and from the patient's health record, remains to be an empirical unknown in the literature [3,16]. Without such knowledge, nurse leaders are at risk for making EHR design and implementation decisions that may omit essential aspects of nurses' information needs and the associated processes of information exchange for the delivery of patient care [15].…”

“…On a patient level, nurses in practice settings pride themselves in "knowing the patient" [3,18,19]. To know the patient, the nurse must have a breadth of clinical and personal patient information to provide individualized care [20].…”

“…The HITECH Act was a response to the widely held assumption that EHRs will improve the quality of care provided to patients [3,[8][9][10][11]. As a result, nurse leaders in US hospital and provider practice settings now have new opportunities to advocate for nursing's role in the use of EHRs.…”

“…Today, nurse leaders would be amiss if their attention and efforts were not drawn toward nursing's use of electronic health records (EHRs) for the delivery of quality care [1][2][3][4]. Thought leaders began advocating for the use of EHRs in the 1960's [5,6].…”

Conformity of nurse prescribing to care needs: nurses' understanding

“…The electronic recording of prescriptions is positive, because it promotes care standardization (12) , data organization, directing nursing actions, and saves time (13) . However, it has also caused a number of problems, since the use of computer systems without employing clinical and critical thinking makes nursing actions automatic and repetitive, which interferes on decision making and care quality (14) . Therefore, this study was conducted to investigate the nurses' understanding of nurse prescribing conformity to the care needs of hospitalized patients and factors associated with that conformity.…”