Background
Nurses have long been known for their attention to patient care. The reason many nurses have entered this profession is due to their desire to care for people. The overwhelming responsibilities of documentation, chart reviews, verifying orders and medications, monitoring lab results, among others, leaves the direct care of the patient to another, possibly unqualified, staff member. Bolton, Gassert, and Cipriano (2008) estimate that a mere 23-30% of a nurse’s day is spent providing care to a patient. This leaves the greater part of a 12-hour shift performing some kind of paperwork. In fact, the inability to provide more patient care has been cited as a reason many nurses leave their job, and the profession altogether (Bolton et al., 2008).
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare team in actually ensuring that pertinent information makes its way to the chart by the end of a shift. Ultimately, this haphazard system leads to the deleterious result that vital information is easily waylaid and lost in the shuffle, never making it to the patient’s permanent record at all. For nurses, the effort spent transferring information from one spot to another takes valuable time away from the patient. Bolton et al. (2008) avow that the presence of nurses at the patient’s bedside is crucial for the early identification of any change in the patient’s condition.
In many healthcare settings, a paper Medication Administration Record (MAR) is still being utilized. Physician orders, both written and oral, must be transcribed from one piece of paper to another piece of paper. This process is often passed through several people before being placed in the patient’s chart. The paper MAR leaves a large margin for error as a result of unclear or illegible orders being transferred from physician to nurse to pharmacy and back. There is clearly a greater risk of drug interactions and double dosing with paper MARs compared to the electronic systems that are now available (Ketchum, 2008). In addition, paper flow sheets, MARs,...
