Nurses' experience of using electronic patient records in everyday practice in acute/inpatient ward settings: A literature review

Recording signs of deterioration in acute patients: The documentation of vital signs within electronic health records in patients who suffered in-hospital cardiac arrest

Vital sign documentation is crucial to detecting patient deterioration. Little is known about the documentation of vital signs in electronic health records. This study aimed to examine documentation of vital signs in electronic health records. We examined the vital signs documented in the electronic health records of patients who had suffered an in-hospital cardiac arrest and on whom cardiopulmonary resuscitation was attempted between 2007 and 2011 (n = 228), in a 372-bed district general hospital. We assessed the completeness of vital sign data compared to VitalPAC™ Early Warning Score and the location of vital signs within the electronic health records. There was a noticeable lack of completeness of vital signs. Vital signs were fragmented through various sections of the electronic health records. The study identified serious shortfalls in the representation of vital signs in the electronic health records, with consequential threats to patient safety.

Attitudes of health professionals towards electronic health records in primary health care settings: a questionnaire survey

PURPOSE

This study aimed to assess the attitudes of health professionals towards electronic health records (EHRs) in primary health care settings in Turkey.

METHODS

A survey was administered to 754 health professionals working in Family Health Centres (FHCs) in seven districts in Istanbul, Turkey. The survey was developed based on extensive literature review, and consisted of 33 statements rated on a five-point Likert-scale.

RESULTS

A total of 325 completed questionnaires were received, representing a 43% response rate, with 97% of respondents being satisfied with the EHR system in the FHCs. There were significant differences between health professional groups (physicians and nurses/midwives) in their perceptions of EHRs decreasing paper-based records, data security in EHRs, and costs of EHRs (p < 0.05). Narrative responses indicated ongoing needs in software development, further support of nursing documentation and training.

CONCLUSIONS

Overall positive attitudes towards EHRs among primary care health professionals in Turkey suggest strong acceptance and use. Recommendations based on the findings include EHR technology refinements, improved clinical documentation using standardized terminologies, and health professional-informed EHR training.

The digital patient

Despite efforts, the detection of patients who are deteriorating in hospital is often later than it should be. Several technologies could provide the basis of a solution. Recording of vital signs could be improved by both automated transmission of the measured parameters to an electronic patient record and the use of unobtrusive wearable monitors that track the patient's physiology continuously. Electronic charting systems could make the recorded vital signs readily available for further processing. Software algorithms could identify such patients with greater sensitivity and specificity than the existing, paper-based track-and-trigger systems. Electronic storage of vital signs also makes intelligent alerting and remote patient surveillance possible. However, the potential of these technologies depends strongly on implementation, with poor-quality deployment likely to worsen patient care.

A survey of student nurses' and midwives' experiences of learning to use electronic health record systems in practice

AIM

The study aimed to investigate student nurses' and midwives' experiences of learning to use electronic health records (EHR) in practice.

BACKGROUND

Good record keeping and documentation are integral to nursing and midwifery practice. As EHRs become more widespread, student nurses and midwives need opportunities to access and learn how to use them in practice.

METHOD

A survey of nursing and midwifery students was conducted using questionnaires (n = 215) and three focus groups: one with midwifery students (n = 6); one with mental health nursing students (n = 5) and one with adult nursing students (n = 6). The University research ethics committee approved the study. The questionnaire data were analysed using SPSS v19. The focus group data were analysed thematically following transcription.

RESULTS

The results presented relate to two themes: 1) Preparation for using EHRs and skills development; 2) Access to EHRs and involvement. Students had variable experiences in relation to opportunities to access and use EHRs, training on EHR systems used in practice and guidance from mentors. Some mentors had concerns about students' legitimacy to access EHRs and verification of students' EHR entries was a challenging issue in some areas.

CONCLUSION

To promote opportunities for students to develop competence in using EHRs in practice, training on EHR systems in use, and clear processes for authorised access, are needed. Following the survey, the University and practice partners collaboratively established formalised EHR training for students with clear governance procedures for access and use.