title: The impact of using electronic patient records on practices of reading and writing.
abstract: The aim of this study was to investigate the use of electronic patient records in daily practice. In four wards of a large hospital district in Finland, N = 43 patients' care and activities were observed and analysed in terms of the Grounded Theory method. The findings revealed that using electronic patient records created a particular process of writing and reading. Wireless technology enabled simultaneous patient involvement and point-of-care documentation, additionally supporting real-time reading. Remote and retrospective documentation was distant in terms of both space and time. The remoteness caused double documentation, reduced accuracy and less-efficient use of time. 'Non-reading' practices were witnessed in retrospective reading, causing delays in patient care and increase in workload. Similarly, if documentation was insufficient or non-existent, the consequences were found to be detrimental to the patients. The use of an electronic patient record system has a significant impact on patient care. Therefore, it is crucial to develop wireless technology and interdisciplinary collaboration in order to improve and support high-quality patient care.
authors.affiliation: School of Health Sciences, Nursing Science, University of Tampere, FinlandDepartment of Musculoskeletal Diseases, Tampere University Hospital, Finland Science Centre, Pirkanmaa Hospital District, FinlandTampere University of Applied Sciences, Finland heleena1@elisanet.fi heleena.laitinen@uta.fi.
authors.forename: Heleena
authors.initials: H
authors.lastname: Laitinen
authors.affiliation: School of Health Sciences, Nursing Science, University of Tampere, Finland Science Centre, Pirkanmaa Hospital District, Finland.
authors.forename: Marja
authors.initials: M
authors.lastname: Kaunonen
authors.affiliation: School of Health Sciences, Nursing Science, University of Tampere, Finland Science Centre, Pirkanmaa Hospital District, Finland.
authors.forename: Paivi
authors.initials: P
authors.lastname: Åstedt-Kurki
mesh_terms: D004282:Documentation / Q000379:methods; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D005387:Finland; D006757:Hospital Units; D006767:Hospitals, District; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D016347:Medical Records Systems, Computerized; D018802:Patient-Centered Care / Q000458:organization & administration*; D011787:Quality of Health Care; D011932:Reading; D016526:Workload; D014956:Writing
keywords: electronic records; interdisciplinary; nursing; patient; point of care; wireless