A Survey of Perianesthesia Nursing Electronic Documentation.

PURPOSE: Electronic health records have become a common part of the perianesthesia care workflow, particularly for data gathering and documentation. The purpose of this survey of perianesthesia nurses was to examine patterns of adoption of electronic health records and their effect on clinical documentation and patient care.

DESIGN: A survey was sent to nurses who are members of the American Society of Perianesthesia Nursing (ASPAN).

METHODS: The electronic documentation survey was sent to the e-mail addresses of 13,339 ASPAN members representing various practice environments across the United States. Results were examined through descriptive statistics.

FINDINGS: About two thirds (66.02%) of the respondents indicated that they could capture 80% of their clinical interactions with the patient. Few nurses indicated that adoption of the EHR was done using a standardized terminology. Respondents (63.99%) overwhelmingly indicated that they spent less time interacting with patients and families because of electronic documentation demands.

CONCLUSIONS: The results pertaining to the impact of the EHR on their practice were fairly mixed with some indication that there was greater access to important patient data, but with a trade-off of less satisfaction and efficiency. Improvements and evaluation of clinical documentation are being done, but ongoing optimization and improvements to the EHR based on the knowledge needs of nurses will help realize the promise of greater quality, safety, and access to data.