Artigo Revisado por pares

Assessing the Impact of an Electronic Medical Record on Nurse Documentation Time

2008; Lippincott Williams & Wilkins; Volume: 26; Issue: 4 Linguagem: Inglês

10.1097/01.ncn.0000304801.00628.ab

ISSN

1538-9774

Autores

Brian Hakes, John Whittington,

Tópico(s)

Nursing Diagnosis and Documentation

Resumo

Work sampling measured nurse documentation time before and after the implementation of an electronic medical record on a medical-surgical nursing unit. Documentation was separated into subprocesses of admissions, discharges, and routine/daily documentations. Production rate of documentation time is defined and measured. The results indicate that there is no difference in documentation time between pre-electronic medical record and post-electronic medical record for admissions and routine/daily documentation time. Post-electronic medical record documentation time was longer than that in the pre-electronic medical record for patients discharged to a nursing home. It was demonstrated that the electronic medical record may reduce documentation time after the adoption of computerized physician order entry.

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