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Electronic Health Record Tools Support of Nurses Clinical Judgment and Team Communication

KOSSMAN, SUSAN P. PhD, RN; BONNEY, LEIGH ANN MSN, RN; KIM, MYOUNG JIN PhD

CIN: Computers, Informatics, Nursing:
doi: 10.1097/01.NCN.0000432122.79452.7b
Continuing Education
Abstract

Nurses need to quickly process information to form clinical judgments, communicate with the healthcare team, and guide optimal patient care. Electronic health records not only offer potential for enhanced care but also introduce unintended consequences through changes in workflow, clinical judgment, and communication. We investigated nurses’ use of improvised (self-made) and electronic health record–generated cognitive artifacts on clinical judgment and team communication. Tanner’s Clinical Judgment Model provided a framework and basis for questions in an online survey and focus group interviews. Findings indicated that (1) nurses rated self-made work lists and medication administration records highest for both clinical judgment and communication, (2) tools aided different dimensions of clinical judgment, and (3) interdisciplinary tools enhance team communication. Implications are that electronic health record tool redesign could better support nursing work.

Author Information

Author Affiliations: Mennonite College of Nursing, Illinois State University, Normal.

This study was funded by a grant from Mennonite College of Nursing at Illinois State University.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Susan P. Kossman, PhD, RN, Mennonite College of Nursing, Illinois State University, Campus Box 5815, Normal, IL 61790-5815 (skossm@ilstu.edu).

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.