A Study on the Effects of EMR on Nursing Documentation

Lee, Chung Hee; Sung, Young Hee; Jung, Yeon Yi; Lee, Jeong Lim

Abstract

To improve the quality of nursing care, we developed and evaluated a Electronic Medical Record (EMR) program designed to maximize productivity and efficiency in our nursing documentation system. Five computerized documentation forms, the clinical observation record, medication, nursing treatments, nursing records, and admission assessment were developed by a nursing informatics team over 5 months and implemented on a cardiovascular unit. In the EMR program, nurses access and record required documentation at the patients besides with a laptop computer instead of using conventional chart. Four categories of data were compared before and after operating EMR program; the time spent in direct patient care, the time spent in nursing documentation, nurses' s job satisfaction, and patients' satisfaction. The result showed a statistically significant increase in the time spent in direct patient care after implementation of EMR system, as well as a decrease in the time spent in nursing documentation. Nurses job satisfaction was increased and patients' satisfaction was decreased, but both were not significant statistically.