Assessing the impact of an electronic medical record on nurse documentation time

Work sampling measured nurse documentation time before and after the implementation of an electronic medical record on a medical-surgical nursing unit. Documentation was separated into subprocesses of admissions, discharges, and routine/daily documentations. Production rate of documentation time is defined and measured. The results indicate that there is no difference in documentation time between pre-electronic medical record and post-electronic medical record for admissions and routine/daily documentation time. Post-electronic medical record documentation time was longer than that in the pre-electronic medical record for patients discharged to a nursing home. It was demonstrated that the electronic medical record may reduce documentation time after the adoption of computerized physician order entry.