Automated Clinical Documentation

Abstract

When a west central Florida hospital prepared to move to an electronic health record with a clinical documentation system, the nursing staff and administration were concerned about the effects that the technology change would have on nursing work behavior. Specifically, would the move toward automation increase the time at the bedside, decrease the time nurses spent on documentation, and decrease time spent on administrative tasks? A time-in-motion study was conducted to specifically measure six categories of nurse work behavior on a progressive cardiac unit. The nurses were observed by data collectors prior to the implementation of the electronic health record and then again a year after the implementation. Results showed a significant increase (P=.000) in the amount of time nurses devoted to direct care. Furthermore, there was a significant increase (P=.000) in the time nurses spent documenting after the implementation of the electronic system. Much of the increased time available for direct care and documentation came from a 12% decrease in the time nurses spent on administrative tasks after implementing the automated documentation system. For this progressive cardiac unit, the move to automated documentation seems to be a positive step in developing a fully interactive computerized system.

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