Electronic Health Records Documentation in Nursing

Abstract

A descriptive study of 100 nursing personnel at a large Magnet hospital in Southwest Florida was conducted to assess their needs, preferences, and perceptions associated with Electronic Health Record (EHR) documentation methods. Nurses' attitudes about the use of EHRs and their perceived effects on patient care were assessed. The five-item, Likert-type attitude scale explained 54% of the variance in attitude scores and demonstrated sound construct validity and internal consistency (r = 0.77). More than one third, 36%, perceived that EHRs had resulted in a decreased workload. The majority of nurses, 64%, preferred bedside documentation but reported that environmental and system barriers often prevent EHR charting at the bedside. Overall, 75% of nurses thought EHRs had improved the quality of documentation and 76% believed electronic charting would lead to improved safety and patient care. Nurses with expertise in computer use, 80%, had a more favorable attitude toward EHRs than those with less expertise. Results have been used to implement clinical system changes.