Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings

Abstract

The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs. Although nurses applaud the EHR, they also indicate dissatisfaction with its design and cumbersome electronic processes. This article describes the views of nurses shared by members of the Nursing Practice Committee of the Missouri Nurses Association; it encourages nurses to share their EHR concerns with Information Technology (IT) staff and vendors and to take their place at the table when nursing-related IT decisions are made. In this article, we describe the experiential-reflective reasoning and action model used to understand staff nurses’ perspectives, share committee reflections and recommendations for improving both documentation and documentation technology, and conclude by encouraging nurses to develop their documentation and informatics skills. Nursing issues include medication safety, documentation and standards of practice, and EHR efficiency. IT concerns include interoperability, vendors, innovation, nursing voice, education, and collaboration.