Biomaterial Database

Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings. 2015

Mary Ann Lavin, and Ellen Harper, and Nancy Barr

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.

UI	MeSH Term	Description	Entries
D007362	Intensive Care Units	Hospital units providing continuous surveillance and care to acutely ill patients.	ICU Intensive Care Units,Intensive Care Unit,Unit, Intensive Care
D009736	Nursing Process	The sum total of nursing activities which includes assessment (identifying needs), intervention (ministering to needs), and evaluation (validating the effectiveness of the help given).	Process, Nursing,Nursing Processes,Processes, Nursing
D009737	Nursing Records	Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress.	Records, Nursing,Nursing Record,Record, Nursing
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D016294	Models, Nursing	Theoretical models simulating behavior or activities in nursing, including nursing care, management and economics, theory, assessment, research, and education. Some examples of these models include Orem Self-Care Model, Roy Adaptation Model, and Rogers Life Process Model.	Nursing Models,Model, Nursing,Nursing Model,Orem Self-Care Model,Model, Orem Self-Care,Models, Orem Self-Care,Orem Self Care Model,Orem Self-Care Models,Self-Care Model, Orem,Self-Care Models, Orem
D057286	Electronic Health Records	Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online CONSUMER HEALTH INFORMATION that is relevant to the health conditions and treatments related to a specific patient.	Electronic Health Record Data,Electronic Medical Record,Electronic Medical Records,Computerized Medical Record,Computerized Medical Records,Electronic Health Record,Medical Record, Computerized,Medical Records, Computerized,Health Record, Electronic,Health Records, Electronic,Medical Record, Electronic,Medical Records, Electronic
D061214	Patient Safety	Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers.	Patient Safeties,Safeties, Patient,Safety, Patient