Electronic Documentation

Nursing is a fast changing profession that has been vital to providing care in the medical setting. Throughout the past several years one of the most recognizable changes in the medical field is the transformation from paper charting to electronic forms of documentation. This has led to a decrease in the amount of paper charting by allowing nurses to use check boxes, cell formatting, and computer databases to keep patients records more accessible and organized. As new forms of technology become available we find that there are often flaws that need to be assessed and corrected to properly implement an optimal computing system. The clinical integration paper examines the positive and negative aspects of electronic documentation in the nursing field as it pertains to time management, patient safety and its efficacy.
It was found that nurses spend the largest proportion of their time at the nurses station documenting and coordinating patient’s care with twenty five to fifty percent, which results in less time spent on patient care (Blair & Smith, 2012). This is alarming knowing that approximately a quarter to half of a nurse’s shift is done sitting in front of a computer documenting the day’s events. At Central Baptist Hospital I believe that more than half a day could be taken up by computer charting. From what I have experienced, a nurse may begin their shift with anywhere between four to six patients. These patients require a general assessment upon arrival on shift followed by detailed documentation from their nurse. As a student it took roughly double the amount of time to enter an assessment into the computer, due to a new computer system I have never used. Once one is aware of the system it can be entered in half the allotted time. However with four to six patients’ data entry could take well over an hour. Additional