Bedside Nurse Documentation Practices: At the Patient Bedside or Not?

Abstract

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.