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Strengths and Limitations of the Electronic Health Record for Documenting Clinical Events

CARRINGTON, JANE M. PhD, RN; EFFKEN, JUDITH A. PhD, RN, FACMI, FAAN

CIN: Computers, Informatics, Nursing: June 2011 - Volume 29 - Issue 6 - pp 360-367
doi: 10.1097/NCN.0b013e3181fc4139
Feature Article

The purpose of this research was to compare nurses' perceptions of the strengths and limitations of the electronic health record with and without nursing languages for documenting and retrieving patient information regarding a clinical event. The effectiveness of the electronic health record to facilitate nurse-to-nurse communication is not well understood. Furthermore, little is known how nurse-to-nurse communication influences patient safety and failure-to-rescue events. This qualitative study used a descriptive design in which open-ended, semistructured interviews were conducted with 37 registered nurses. Qualitative content analysis produced 260 thematic units from which five categories emerged: usability, legibility, communication, workarounds, and collaboration. Nurses perceived aspects of usability as strengths (retrievability) and limitations (lack of efficiency and barriers) of the electronic health record. Furthermore, within the category communication, lack of relevance of the documentation was also viewed as a limitation by the nurses. Nurses suggested that they be involved in electronic health record decisions and that hospitals try to reduce the identified barriers to electronic health record use.

Author Affiliations: College of Nursing, University of Colorado, Denver (Dr Carrington); College of Nursing, University of Arizona, Tucson (Dr Effken).

This research was supported by the Department of Veteran's Affairs.

Portions of the data presented in this article were reported at the Nursing Informatics Work Group Tutorial at the American Medical Informatics Association Meeting, November 2008.

Corresponding author: Jane M. Carrington, PhD, RN, College of Nursing, University of Colorado, Denver, Mail Stop C288-19, 13120 E 19th Ave, Room 4227, PO Box 6511, Aurora, CO 80045 (Jane.carrington@ucdenver.edu).

© 2011 Lippincott Williams & Wilkins, Inc.