Nursing Documentation Time During Implementation of an Electronic Medical Record

Abstract

Despite charting concurrently on both paper and computer, the amount of time spent on documentation was not excessive, and was consistent with previous studies in which neither electronic nor "double charting" occurred.

Impact of Bar-code Medication Administration on Nursing Activity Patterns and Usage Experience in Taiwan

“…17,22 Activities are classified based on research purposes, and most would divide nursing activities into five categories: direct care, indirect care, documentation, unit-related activity, and personal activity. [13][14][15]17,23 To understand the work of nurses and properly record their observed activities on the instrument, each observer must have clinical knowledge, such as a senior nurse with nursing experience 13 or a trained medical student 14 or senior nursing students. 15 For limiting the interrater reliability, related training and tests must be given to each observer, including the data collection format, coding, description, and guidance.…”

“…However, another study showed that the time nurses spent charting was not statistically changed when they used computers for documentation. 10 A study 14 revealed that during the implementation of an electronic medical records system, the total percentage of the nursing documentation was 15.8% (10.6% on paper and 5.2% on the computer), and the percentages of time spent on different categories of bedside care and indirect care were significantly related to the day and night shift. Another 15 explored the nursing activity patterns 1 month (time 1) and 1 year (time 2) after the implementation of a nursing information system.…”

“…Several studies have used methods such as time and motion [8][9][10][11][12] or work sampling [13][14][15][16][17] to measure and analyze nurses and other healthcare providers' activities as a result of technology use, but most have focused on documentation outcome only. [8][9][10][13][14][15][16][17] Although researchers have studied time spent on medication-related activities, they have mostly used time-and-motion observation, 11,12 but have seldom deployed the work sampling method.…”

“…[8][9][10][13][14][15][16][17] Although researchers have studied time spent on medication-related activities, they have mostly used time-and-motion observation, 11,12 but have seldom deployed the work sampling method. Nonetheless, working sampling, a method of using a small number of individual activities to estimate a large number of work patterns, seems appropriate for observing nursing activities with varied As medication safety is a foremost goal of patient safety, the adoption of bar-code medication administration can help nurses ensure safe medication administration.…”

Implementing Information Technology in a Behavioral Health Setting

“…Another benefit is decreased time spent charting. One team of researchers reported that nurses spent 10.6% of their time documenting when charting on paper but only 5.2% on computer charting (Korst, Eusebio-Angeja, Chamorro, Aydin, & Gregory, 2003). Zolot (1999) estimated a much higher number for paper charting, asserting that as much as 50% of nursing time is spent documenting on paper.…”