Case study: nursing documentation in the electronic age

 

You are caring for five patients on a busy, 28-bed neurological medical-surgical unit, which recently transitioned to all electronic documentation and healthcare computerized provider order entry (CPOE). There is no longer any bedside paperwork.

All of your staff members have completed the required training and you have been assigned as expert lead for any questions that may arise during your shift. The expectation is that all nurses and clinical staff will document all care delivery in the bedside computers located in each patient’s room or via the workstation on wheels (WOW).

However, you have noticed a trend with experienced nurses spending extra time at the end of their shifts (30 or more minutes) documenting the nursing care provided during the shift. The expectation is that they should be documenting care delivery as soon as it is complete rather than at the end of their shifts.

Answer the following questions based on the information provided:

  1. Explain how you would address the concern with the delay in nursing documentation with your team.
  2. Do you see the transition to all electronic documentation as having a positive or negative effect on patient-centered care? Support your answer with evidence from the literature.
  3. Explore the role of advancement in information technology and its effect in patient care. Does more technology use improve time with patients? Use at least two sources to support your response.
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