Use of Electronic Health Records by Nurses for Symptom Management in Inpatient Settings: A Systematic Review

Area of Science:

• Nursing Informatics
• Health Information Technology
• Patient Symptom Management

Background:

• Symptom management is a core nursing function in inpatient settings.
• Nurses' use of electronic health records (EHRs) for symptom documentation is not well understood.
• Effective EHR use is vital for quality and safety in patient care.

Purpose of the Study:

• To systematically review and characterize nurses' EHR use for symptom assessment and management documentation.
• To identify challenges nurses face when using EHRs for symptom documentation.
• To inform the design of EHR systems that better support nurses in patient symptom management.

Main Methods:

• Systematic review of literature from Ovid Medline, CINAHL, and Embase databases (inception to May 2015).
• Search terms included "electronic medical records," "symptom documentation," and "inpatient setting."
• Included 18 publications from 2003-2014 after abstract and full-text review.

Main Results:

• Studies predominantly focused on pain as the primary symptom documented.
• Nurses encounter significant challenges with EHRs, potentially impacting care quality and safety.
• Clinical, design, and administrative recommendations were identified to address these challenges.

Conclusions:

• Interdisciplinary, systematic interventions and user-centered design are needed for EHR information systems.
• Addressing EHR usability challenges is essential for effective nursing symptom management.
• Further research should focus on optimizing EHRs to support comprehensive symptom documentation by nurses.