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Automated clinical documentation: does it allow nurses more time for patient care?
Laura Banner1, Christine M Olney
1Clinical Informatics Department, University Community Health, Tampa, FL 33613, USA. LBanner@mail.uch.org
Computers, Informatics, Nursing : CIN
|June 21, 2011
Summary
Implementing electronic health records (EHR) with clinical documentation systems increased nurses
Area of Science:
- Nursing Informatics
- Healthcare Technology Integration
- Clinical Workflow Analysis
Background:
- Hospitals transitioning to electronic health records (EHR) face concerns regarding impacts on nursing work behavior.
- Key concerns include changes in direct patient care time, documentation duration, and administrative task load.
Purpose of the Study:
- To evaluate the effects of implementing an EHR with a clinical documentation system on nursing work behavior.
- To measure changes in time spent on direct patient care, documentation, and administrative tasks.
Main Methods:
- A time-in-motion study was conducted on a progressive cardiac unit.
- Nurse work behaviors were observed and measured before and one year after EHR implementation.
Main Results:
- Significant increases (P=.000) were observed in time spent on direct patient care.
- Significant increases (P=.000) were observed in time spent on documentation.
- A 12% decrease in time spent on administrative tasks was noted post-implementation.
Conclusions:
- The transition to automated documentation within an EHR system positively impacted nursing work behavior on this progressive cardiac unit.
- Increased direct care and documentation time, facilitated by reduced administrative tasks, suggest a beneficial move towards a computerized system.
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