Electronic medical record in the simulation hospital: does it improve accuracy in charting vital signs, intake, and output?
The introduction of electronic health records has created a shift in the way nursing care is delivered (McBride, Delaney, & Tietze, 2012; Furukawa, Raghu, & Shao, 2010). A factor which heavily influences a nurse’s ability to navigate and utilize EMR is adequate education in the use of computerized documentation (McBride, et al., 2012). There is an increased risk for error at the bedside without the correct knowledge and skills regarding EMR documentation (Kelly, Brandon, & Docherty, 2011). This skill should be introduced during the pre-licensure education of the nurse. Two groups of associate degree nursing students attending a small community college in Northern California were examined to determine if introduction of EMR in the simulation hospital increased accuracy in documenting vital signs, intake, and output. The first group of students charted using paper- pencil during simulation; the second group used an academic EMR. Each group was evaluated during their preceptor rotation at two local inpatient facilities. Registered nurse preceptors provided information by responding to a 10 question survey regarding the use of student EMR documentation during the 120 hour preceptor rotation. The implementation of the EMR into the simulation hospital, although a complex undertaking, provided students a safe environment in which to practice using technology and receive feedback from faculty regarding accurate documentation.