title: Electronic medical record in the simulation hospital: does it improve accuracy in charting vital signs, intake, and output?
abstract: Nursing care delivery has shifted in response to the introduction of electronic health records. Adequate education using computerized documentation heavily influences a nurse's ability to navigate and utilize electronic medical records. The risk for treatment error increases when a bedside nurse lacks the correct knowledge and skills regarding electronic medical record documentation. Prelicensure nursing education should introduce electronic medical record documentation and provide a method for feedback from instructors to ensure proper understanding and use of this technology. RN preceptors evaluated two groups of associate degree nursing students to determine if introduction of electronic medical record in the simulation hospital increased accuracy in documenting vital signs, intake, and output in the actual clinical setting. During simulation, the first group of students documented using traditional paper and pen; the second group used an academic electronic medical record. Preceptors evaluated each group during their clinical rotations at two local inpatient facilities. RN preceptors provided information by responding to a 10-question Likert scale survey regarding the use of student electronic medical record documentation during the 120-hour inpatient preceptor rotation. The implementation of the electronic medical record into the simulation hospital, although a complex undertaking, provided students a safe and supportive environment in which to practice using technology and receive feedback from faculty regarding accurate documentation.
authors.affiliation: Author Affiliations: Associate Degree Nursing, Shasta College, Redding (Drs Mountain and Redd); Simulation Program, San Jose State University (Dr O'Leary-Kelly); and Clinical Skills Lab, Shasta College, Redding (Ms Giles), CA.
authors.forename: Carel
authors.initials: C
authors.lastname: Mountain
authors.forename: Roxanne
authors.initials: R
authors.lastname: Redd
authors.forename: Colleen
authors.initials: C
authors.lastname: O'Leary-Kelly
authors.forename: Kim
authors.initials: K
authors.lastname: Giles
mesh_terms: D004508:Education, Nursing, Baccalaureate; D057286:Electronic Health Records; D006761:Hospitals; D006801:Humans; D009737:Nursing Records / Q000592:standards*; D000066908:Simulation Training; D013338:Students, Nursing; D055986:Vital Signs