title: Assessing the impact of an electronic medical record on nurse documentation time.
abstract: Work sampling measured nurse documentation time before and after the implementation of an electronic medical record on a medical-surgical nursing unit. Documentation was separated into subprocesses of admissions, discharges, and routine/daily documentations. Production rate of documentation time is defined and measured. The results indicate that there is no difference in documentation time between pre-electronic medical record and post-electronic medical record for admissions and routine/daily documentation time. Post-electronic medical record documentation time was longer than that in the pre-electronic medical record for patients discharged to a nursing home. It was demonstrated that the electronic medical record may reduce documentation time after the adoption of computerized physician order entry.
authors.affiliation: System Solutions for HealthCare, Peoria, IL, USA. bhakes@sbcglobal.net
authors.forename: Brian
authors.initials: B
authors.lastname: Hakes
authors.forename: John
authors.initials: J
authors.lastname: Whittington
mesh_terms: D017598:Efficiency, Organizational; D016347:Medical Records Systems, Computerized; D009737:Nursing Records; D013996:Time and Motion Studies