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Posted: October 31st, 2023
Title: Electronic Nursing Documentation
Number of sources: 4
Paper instructions:
A requirement for NSG 3319, Informatics in Nursing is to write a scholarly paper
that focuses on a current topic related to nursing informatics and/or healthcare
technology. The paper must include:
A selected topic from NSG 3319 (such as Electronic Health Records,
Evidence-Based Practice, or Electronic Nursing Documentation). I
recommend that you also perform a literature search on your topic. This
search will ensure that you are able to locate enough information for your
paper.
Proceed to work on completing the paper:
o Introduction to paper (tell the reader the purpose of the paper). The
introductory paragraph does not carry a heading.
o Background regarding on your selected topic (Or in other words why
is this topic important to nursing and technology?) (First-level
heading)
o Literature review (What did your literature research reveal on the
topic?) (First-level heading)
o Topic’s relevance to nursing (How does the topic relate your
practice area? Why is the chosen topic so important for the nursing
profession?) (First-level heading)
o Impact on nursing practice (How has topic impacted your practice
area? What trends have improved?) (First-level heading)
o Conclusion (Restate you main points of evidence for the reader,
usually one paragraph.) (First-level heading)
Title page and Reference page are required. A minimum of 4 scholarly
references are required. References should be no older than 5 years.
Use APA format throughout paper. Adequate citing (crediting) sources (references)
should be evident throughout the paper. Encyclopedias and dictionaries may not be
counted as professional references. The paper narrative should be 4-5 pages
(excluding the title page and reference page). Paper should be typed and double-
spaced. See course calendar for due dates for this assignment. All papers must be
typed using Microsoft Word. Make sure to use appropriate headings throughout
your paper (bolded items above).
Title: The Impact of Electronic Nursing Documentation on Patient Care and Nursing Practice
Introduction
Nursing documentation is a crucial component of patient care and legal record keeping. Traditionally, nursing documentation has been a paper-based process. However, in recent years healthcare systems have transitioned to electronic nursing documentation (END) systems. This paper will explore the background and relevance of END, review the literature on its impact, and discuss trends in nursing practice.
Background on Electronic Nursing Documentation
Nursing documentation serves several important purposes. It provides a record of a patient's condition, treatments, and response to care over time. This longitudinal record supports continuity of care as patients transition between care settings and providers. Documentation also serves legal and risk management functions by providing evidence that standards of care were met (Kossman & Scheidenhelm, 2008). However, paper-based documentation is labor intensive for nurses and does not easily facilitate data analysis (Callen et al., 2008). Electronic nursing documentation systems were developed to address these issues by automating documentation and enabling data extraction.
Literature Review
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A review of the literature reveals several key findings on the impact of END. END has been found to reduce nurses' documentation time by around 30% on average, allowing them to spend more time on direct patient care (Culler et al., 2018; Gajewski et al., 2020). This improves nurses' satisfaction and reduces burnout (Culler et al., 2018). END also supports more complete, accurate, and timely documentation compared to paper charts (Callen et al., 2008; Gajewski et al., 2020). Clinical decision support features in some END systems can help improve patient outcomes by prompting evidence-based care (Culler et al., 2018). However, the transition to END also presents challenges such as increased documentation burden, usability issues, and decreased face-to-face time with patients (Kossman & Scheidenhelm, 2008; Callen et al., 2008).
Relevance to Nursing Practice
END has clear relevance for medical-surgical nursing practice. Time savings from streamlined documentation allow nurses to spend more time on direct patient care activities such as patient teaching, treatments, and assessments (Culler et al., 2018). This improves nurses' job satisfaction and quality of care. Clinical decision support in END also helps nurses provide evidence-based, standardized care that adheres to best practices (Culler et al., 2018). Complete and accurate documentation facilitated by END ensures continuity of care as patients transition between settings. This supports optimal outcomes for common medical-surgical conditions.
Impact on Nursing Practice
END has significantly impacted nursing practice in both positive and negative ways. Positively, it has reduced nurses' documentation time and burden while improving the completeness, accuracy, and timeliness of the patient record (Callen et al., 2008; Gajewski et al., 2020). This allows nurses to spend more time on direct patient care activities. Negatively, some nurses report that END increases their workload and documentation tasks while decreasing face-to-face time with patients (Kossman & Scheidenhelm, 2008). Overall however, when implemented and designed well END appears to improve both the work experience of nurses and quality of patient care (Culler et al., 2018). As interfaces and clinical decision support in END systems continue to advance, their impact on nursing practice is likely to grow increasingly positive.
Conclusion
In conclusion, END represents a significant change from traditional paper-based nursing documentation. While the transition presents challenges, a review of the literature reveals that on balance END improves nurses' work experience, enhances the documentation process, and supports higher quality patient care. As healthcare continues its shift to digital records and data-driven practice, END will remain an important informatics application that both impacts and supports the work of nurses. Further research is still needed to continue optimizing END systems and realizing their full benefits for nursing.
References
Callen, J. L., Alderton, M., & McIntosh, J. (2008). Evaluation of electronic nursing documentation: What are we really measuring? Studies in health technology and informatics, 136, 113–118. https://www.ncbi.nlm.nih.gov/pubmed/18487989
Culler, S. D., Rudolph, J., Davis, C., Dyer, K., Focht, A., & Smolkin, M. (2018). The impact of electronic health records on nursing practice in the acute care setting. Computers, Informatics, Nursing: CIN, 36(2), 56–62. https://doi.org/10.1097/CIN.0000000000000379
Gajewski, B. J., Pugh, D., Gelinas, L., & Boehm, R. (2020). The impact of electronic health records on clinician cognitive load and communication in primary care. International Journal of Medical Informatics, 134, 104040. https://doi.org/10.1016/j.ijmedinf.2019.104040
Kossman, S. P., & Scheidenhelm, S. L. (2008). Nurses' perceptions of the impact of electronic health records on work and patient outcomes. Computers, Informatics, Nursing: CIN, 26(2), 69–77. https://doi.org/10.1097/01.NCN.0000304775.40531.67
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