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Assessing the impact of an electronic medical record on nurse documentation time
Brian Hakes1, John Whittington
1System Solutions for HealthCare, Peoria, IL, USA. bhakes@sbcglobal.net
Abstract:
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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