Nursing Documentation In The Electronic
Age 5
Nursing Documentation In The Electronic Age 5
You are caring for five patients on a busy, 28-bed neurological
medical-surgical unit, which recently transitioned to all electronic
documentation and healthcare computerized provider order entry
(CPOE). There is no longer any bedside paperwork.
All of your staff members have completed the required training
and you have been assigned as expert lead for any questions that
may arise during your shift. The expectation is that all nurses and
clinical staff will document all care delivery in the bedside
computers located in each patient’s room or via the workstation
on wheels (WOW).
However, you have noticed a trend with experienced nurses
spending extra time at the end of their shifts (30 or more minutes)
documenting the nursing care provided during the shift. The
expectation is that they should be documenting care delivery as
soon as it is complete rather than at the end of their shifts.
Answer the following questions based on the information
provided:
Explain how you would address the concern with the delay in
nursing documentation with your team.
Do you see the transition to all electronic documentation as
having a positive or negative effect on patient-centered care?
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