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Abstract: 

Driven primarily by concerns around patient safety, the electronic health record is now federally mandated in all health care organizations across the United States as an auspicious approach to ensure patients remain safe. The paradigm shift to electronic recording occurred because of the alarming rates of medical errors resulting from incorrect deciphering of physicians handwritten documentation. The purpose of this study was to investigate the lived experiences of nurses working on a medical unit using the electronc health record to document nursing care. Nurses are the primary end-users of the electronic health record and little research is available on the qualitative aspect of nurses’ perspectives regarding the use of the electronic health record in documenting nursing care. Using a hermeneutic phenomenological research design, the sample consisted of 14 nurses working on the medical units of one of the major hospitals in New York City. The analysis revealed six essential themes–comprehensive picture of the patient, user friendliness, decreased medication errors, effective documentation, optimized/prioritization of plan of care, and increased staff interactions. The findings could assist electronic health record system designers to refine an electronic documentation system that is more nursing-centered, which will enhance nursing practice, patient outcomes, and the promotion of excellence in the delivery of health care.

This publication has been peer reviewed.
Publication Type: 
Journal Article
Authors: 
Candace Marrast
Margaret Kroposki
Year of Publication: 
2016
Journal, Book, Magazine or Other Publication Title: 
Computers, Informatics, Nursing
Publication Language: 
English
Boyer's Domain: 

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