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Nurses' Perception of the Impact of Electronic Documentation on the Nurse-Patient Relationship
Kara Misto1, Cynthia Padula, Elizabeth Bryand
1Rhode Island College, Providence (Drs Misto and Padula); The Miriam Hospital, Providence, Rhode Island (Dr Padula); Newport Hospital, Newport, Rhode Island (Ms Bryand); and Lifespan Oncology Clinical Research, The Miriam Hospital, Providence, Rhode Island (Ms Nadeau). Ms Bryand was formerly with The Miriam Hospital, Providence, Rhode Island.
Background:
While there are many benefits of electronic medical record documentation, the presence of a computer may adversely affect provider-patient interaction.
Purpose:
The purpose of this project was to examine staff nurses' perception of the impact of electronic documentation in the presence of the patient on the nurse-patient relationship.
Methods:
A survey was administered to 276 staff nurses, and open-ended interviews were conducted with 11 novice and 20 expert nurses.
Results:
Nurses identified benefits and challenges to electronic medical record documentation as well as strategies used to maintain therapeutic relationships and communication. Numerous nurses commented that documenting with their back to the patient had a negative impact on the nurse-patient relationship and communication.
Conclusions:
Both novice and expert nurses identified strategies that they used to ensure they were "maintaining the connection" to patients during electronic medical record documentation.
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Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
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