Author Affiliation: Research & Development, Center of Innovation (COIN), Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Medical University of South Carolina.
Comput Inform Nurs. 2024 Sep 1;42(9):629-635. doi: 10.1097/CIN.0000000000001165.
High-quality care requires precise and timely provider documentation. Hospitals have used technology to document patient care within both the inpatient and outpatient areas and long-term care facilities. Research has demonstrated, by revealing a reduction in medical errors, that there has been a worldwide improvement in our community health and welfare since the implementation and utilization of documenting patient care electronically. Although electronic documentation has proven to be an improvement in patient record keeping, the most efficient location in which this documentation is to occur remains a question. At the location where this project took place, only the ICU had computers within the patient rooms for documentation purposes. This project evaluated bedside nurses' opinions related to the efficiency of documentation practices compounded by the location where documentation took place. The options were at the patient's bedside, on a workstation on wheels, or at the nursing station. Surveys were provided to bedside nursing staff both before and after computers were installed in patients' rooms in surgical and medical/surgical nursing units at a Veteran Affairs Medical Center located in the Northeastern region of the United States. The results of this project inconclusively answer the question posed: "Which mode of entry do nurses feel is more efficient to document patient care, on a computer in the patient room, at the nurses' station, or on a workstation on wheels?" Innovative strategies should be explored to develop a user-friendly design for computers located within the patient rooms for patient documentation.
高质量的护理需要精确和及时的提供者文件记录。医院已经在住院和门诊以及长期护理设施中使用技术来记录患者护理情况。研究表明，自电子记录患者护理以来，通过减少医疗差错，我们的社区健康和福利在全球范围内得到了改善。虽然电子文档记录已被证明是患者记录保存方面的一项改进，但最有效的文档记录位置仍然是一个问题。在这个项目实施的地点，只有 ICU 病房在每个病房内配备了电脑用于文件记录。这个项目评估了床边护士对文件记录效率的看法，以及文件记录位置的影响。这些选项包括在患者床边、带轮子的工作站上或护士站。在位于美国东北部的退伍军人事务医疗中心的外科和内科/外科护理单元，在为患者的病房安装电脑之前和之后，都向床边护理人员提供了调查。该项目的结果并没有明确回答提出的问题：“护士认为哪种记录患者护理的方式更有效率，是在患者病房的电脑上、护士站还是带轮子的工作站上？”应该探索创新策略，为位于患者病房内的电脑设计用户友好的界面，以方便患者文档记录。
