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Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...

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Role of Communication in the Nursing Process III: Evaluation and Documentation

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A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:

Nursing Clinical Information System

Nursing Clinical Information System

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Documentation of Nursing Diagnosis

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The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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Nursing Evaluation

The evaluation stage signals the end of the nursing process. The nurse gathers evaluative data to assess whether or not the patient has attained the expected results. Whereas the nurse collects data in the nursing assessment to identify the patient's health concerns, the evaluation stage data determines if the indicated health issues are resolved. Evaluative data collection includes two sections: the data acquired to evaluate patient outcomes and the time criteria for data collection.
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Related Experiment Video

Updated: May 28, 2026

Improving IV Insulin Administration in a Community Hospital

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

Nursing satisfaction with implementation of electronic medication administration record.

Patty J Moreland¹, Sue Gallagher, James F Bena

¹Nursing Informatics, Cleveland Clinic, OH 44195, USA. morelap@ccf.org

Computers, Informatics, Nursing : CIN

|October 14, 2011

Summary

Electronic medication administration record (eMAR) systems improved nurses' satisfaction, workload, teamwork, ease of documentation, drug accuracy, and patient safety over six months. However, nurse/pharmacy communication requires separate attention for optimal medication safety.

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Last Updated: May 28, 2026

Improving IV Insulin Administration in a Community Hospital

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

Area of Science:

Health Informatics
Nursing Practice
Patient Safety

Background:

Nurses' perceptions of electronic medication administration record (eMAR) documentation compared to traditional methods are not fully understood.
Key areas of concern include workload, teamwork, documentation ease, drug information accuracy, patient safety, and overall satisfaction.

Purpose of the Study:

To evaluate nurses' perceptions of eMAR documentation over time.
To assess changes in workload, teamwork, ease of documentation, drug information accuracy, patient safety, and overall satisfaction post-eMAR implementation.

Main Methods:

A longitudinal survey design was employed.
Nurses completed the Nursing Satisfaction with eMAR instrument at baseline, 3 months, and 6 months post-implementation.
Data were analyzed using comparative statistics, correlational statistics, and multivariable regression.

Main Results:

eMAR documentation was associated with perceived improvements in nurse satisfaction, workload, teamwork, ease of documentation, drug information accuracy, and patient safety over time (P < .001).
Satisfaction with eMAR improved significantly across time periods (P < .02), with the largest gains between baseline and 6 months (P < .001).
eMAR did not improve nurse/pharmacy communication.

Conclusions:

eMAR systems are linked to enhanced nurse satisfaction and perceived improvements in key practice areas.
Despite eMAR benefits, nurse/pharmacy communication remains a critical area needing separate, improved systems for safe medication administration.