Kohle-Ersher Angela, Chatterjee Pooja, Osmanbeyoglu Hatice Ulku, Hochheiser Harry, Bartos Christa
School of Nursing, University of Pittsburgh, PA 15261, USA.
Comput Inform Nurs. 2012 Mar;30(3):126-33. doi: 10.1097/NCN.0b013e3182343f14.
Point-of-care documentation has been identified as a patient safety measure for improving accuracy and timeliness of data. To evaluate the barriers that nurses and nurse aide/clinical technicians encounter for electronic point-of-care documentation, we conducted surveys on a telemetry unit at a southwestern Pennsylvania community hospital. Our first survey revealed that the location of the in-room computers, perceived lack of in-room computer reliability, Health Insurance Portability and Accountability Act/privacy concerns, and perceptions of the patients' response to charting on computers in patient rooms were all barriers to point-of-care documentation. Our second survey revealed that workflow priority issues were also a barrier to point-of-care documentation, as staff members did not rate documentation as a high priority in terms of delivering timely medical care. Changes in both nursing practices and hospital infrastructure may be needed if these barriers to point-of-care documentation are to be overcome.
床边护理记录已被视为一项患者安全措施，用于提高数据的准确性和及时性。为了评估护士和护理助理/临床技术员在电子床边护理记录方面遇到的障碍，我们在宾夕法尼亚州西南部一家社区医院的遥测病房进行了调查。我们的第一次调查显示，病房内电脑的位置、认为病房内电脑可靠性不足、《健康保险流通与责任法案》/隐私问题以及对患者对病房内电脑记录的反应的看法，都是床边护理记录的障碍。我们的第二次调查显示，工作流程优先级问题也是床边护理记录的障碍，因为工作人员在提供及时医疗护理方面并未将记录视为高度优先事项。如果要克服这些床边护理记录的障碍，可能需要改变护理实践和医院基础设施。
