Role of Electronic Health Records in Enhancing Nursing Documentation in Medical-Surgical Units

Abstract

EHR (Electronic Health Records) have become a revolutionary force in contemporary healthcare, especially in relation to advancing the quality and efficiency of nursing documentation in medical-surgical units. This study, which focused on EHR systems to demonstrate documenting practices, found not only that accuracy, accessibility, and standardization of records of care provided to patients improved when documented in EHR, but also that by transitioning from paper-based documentation, EHR supports immediate entry of data, includes features to reduce documentation errors, and expedites communication among interdisciplinary team members in real-time. The EHR electronic document features of medical-surgical units also provide nurses with structures of templates, automated notifications, and other decision-support technologies, which foster more accurate assessment documentation, continuity of care, and adherence to clinical practice guidelines. EHR improves patient safety through improved medication administration records, redundancy of documentation recorded in the medical record, and adoption of health information technology breaking barriers to communication. Challenges to practice associated with EHR include perception of increased workload, training access, and usability flaws; however, EHR ultimately supports evidence-based practice and benefits patient outcomes of care overall. This abstract demonstrates that while EHR may change practices of documentation, nursing patients in medical-surgical units positively strengthens documentation practices and supports the subsequent quality, safety, and efficiency of care delivered in healthcare settings.