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Why Bedside Nurses Should Love Electronic Documentation

Written by: James Farrell, RN, MBA on Thursday, October 1, 2015 Posted in: Inpatient Rehab

For many nurses, the very idea of electronic documentation seems incongruent with good nursing care.  If you have been on the front end of the implementation of a new electronic medical record (EMR), you may have seen bedside nurses retire or resign to avoid having to learn electronic documentation.  There are even articles that some nurses will cite that point to increased time required to document in an EMR versus documenting on paper.  That leads the nurses to conclude that an EMR is antithetical to good patient care.  Taking nurses’ time away from bedside care is clearly not good for patients, right?  Quoting from a Saturday morning sports analyst, “Not so fast my friend.”

I would submit to you that nurses should love electronic documentation but with a caveat. If nurses are thinking of electronic documentation only as typing and choosing selections in boxes so that they can meet the latest regulations, then no, electronic documentation is clearly more time consuming and no better than documenting on paper.  However, what I am referring to is the ability to make meaningful use of the data.  That is where electronic documentation is vastly superior to paper documentation.  Capturing data, pulling it into a report and then developing analytics around it to support improved clinical processes is more possible and more efficient in the world of electronic documentation.

Consider the following scenario.  A nurse admits a patient who had a left hemispheric ischemic stroke to the rehabilitation unit.  The team captures the patient’s functional scores in the first three days.  The family is concerned and wants to know what kind of prognosis they can expect.  In the world of documenting on paper, the clinician may be able to review studies or other resources to help the family make post rehabilitation care decisions, but are those studies accurate or even applicable to this patient in this setting?  In the electronic world, nurses can see the history of patients on the unit with similar diagnoses and functional scores to project likely discharge functional levels.

In another scenario, a patient has a blood pressure of 90/60.  The nurse is concerned because that seems low, and she is unsure if the patient is losing blood or going into hypovolemic shock.  In the world of paper documentation, the nurse can flip to the graphics and look for trends, then flip a few more pages to review labs.  Additionally, the nurse can flip pages and read the narrative notes for signs of altered levels of consciousness previously noted in the patient’s admission.  Taking all that information into account, the nurse would then determine if the patient’s blood pressure, labs and level of consciousness are evidence of possible hypovolemic shock.  In the electronic world, this information can all be captured in one or a couple of flowsheets and reviewed for patterns and changes.  Not only is it more efficient to review information in an EMR but the likelihood of doing so is greater because an EMR removes problems of legibility and availability of records  inherent to a paper medical record.

While maximizing the benefits of an EMR may take time and effort to learn, the long-term results and improved patient outcomes are worth the time invested.