Bedside Nurse Documentation Practices: At the Patient Bedside or Not?

Area of Science:

• Health Informatics
• Nursing Practice
• Patient Care Technology

Background:

• High-quality healthcare relies on precise and timely provider documentation.
• Electronic documentation has improved patient record keeping and reduced medical errors globally.
• The optimal physical location for electronic patient care documentation remains an open question.

Purpose of the Study:

• To evaluate bedside nurses' opinions on the efficiency of documentation practices based on location.
• To compare nurse perceptions of documentation efficiency at the patient's bedside, workstation on wheels (WOW), and nursing station.

Main Methods:

• Surveys administered to bedside nursing staff before and after in-room computer implementation.
• Study conducted in surgical and medical/surgical units at a Northeastern US Veteran Affairs Medical Center.
• Evaluated nurse opinions on documentation efficiency across three distinct locations.

Main Results:

• The study yielded inconclusive results regarding the most efficient documentation location.
• Nurses' perceptions of efficiency varied across bedside, WOW, and nursing station settings.
• Further research is needed to definitively determine the optimal documentation environment.

Conclusions:

• While electronic documentation is beneficial, its most efficient implementation setting requires further investigation.
• Innovative strategies and user-friendly designs for in-room patient documentation systems should be explored.
• Optimizing documentation location is crucial for enhancing nursing workflow and patient care quality.