Strengths and limitations of the electronic health record for documenting clinical events

The purpose of this research was to compare nurses' perceptions of the strengths and limitations of the electronic health record with and without nursing languages for documenting and retrieving patient information regarding a clinical event. The effectiveness of the electronic health record to facilitate nurse-to-nurse communication is not well understood. Furthermore, little is known how nurse-to-nurse communication influences patient safety and failure-to-rescue events. This qualitative study used a descriptive design in which open-ended, semistructured interviews were conducted with 37 registered nurses. Qualitative content analysis produced 260 thematic units from which five categories emerged: usability, legibility, communication, workarounds, and collaboration. Nurses perceived aspects of usability as strengths (retrievability) and limitations (lack of efficiency and barriers) of the electronic health record. Furthermore, within the category communication, lack of relevance of the documentation was also viewed as a limitation by the nurses. Nurses suggested that they be involved in electronic health record decisions and that hospitals try to reduce the identified barriers to electronic health record use.