Electronic health record documentation of nursing care: A hermeneutic investigation.

摘要

There have been many changes in nursing practice and nursing documentation. One recent change is the transition to the electronic health record (EHR). Over the past 10 years, health care facilities began implementing the EHR and now electronic recording has widely replaced the traditional paper-based format. Driven primarily by concerns around patient safety, the EHR is in the process of becoming mandatory in all health care organizations across the United States. The purpose of this study was to investigate the lived experiences of nurses working on a medical unit using the EHR to document nursing care. The study used a hermeneutic phenomenological research approach and responded to research questions in the context of Max Van Manen's approach to phenomenology and the Theory of Acceptance Model. Consideration of the salient issues intrinsic in these theories directed the formulation of semi-structured prompts, which constituted the primary data collection method. The sample consisted of 14 nurses working on the medical units of one of the major hospitals in New York City. Hermeneutic phenomenological data analysis using Modell's 1992 three-step method along with the Colaizzi's 1978 phenomenological method, and the QSR Nvivo 10 software revealed six essential themes-comprehensive picture of the patient, user friendliness, decreased medication errors, effective documentation, optimized /prioritization of plan of care, and increased staff interactions. The study findings could assist in the development and refining of the EHR as a documentation mechanism for enhancing nursing practice, patient outcomes, and the promotion of excellence in the delivery of health care.