Opportunities and Challenges Electronic Health Records Documentation from the Perspective of Nurses

Background: Nurses are one of the main groups in patients recording. As the health care arena is changing rapidly in the development and utilization of electronic records, there is an opportunity to enhance the visibility of nurse practice through documentation in the Electronic Health Record (HER). This study was aimed at assessing the opportunities and challenges of nursing documentation in EHR from nurses' perspective.

Methods: This Applied-descriptive study was performed in 2012. Data collected using self-developed questionnaire was confirmed by experts (validity) and its reliability was measured using of Cronbach's alpha (%86). The sample was consisted of 150 nurses working at the 4 hospitals of Tehran University of Medical Sciences that were selected by Quato sampling method. The data was analyzed by SPSS using descriptive statistics.

Results: Nurses had a positive attitude towards all the opportunities in EHR documentation    (=3/95), the highest scores were related to opportunities "improvement in legal requirements for documentation" (=4/18). Also they were agreed with all items related to the challenges of electronic documentation (=4/02) and the most important challenges was the "risk of technical problems" (=4/10).

Conclusion: Appropriate strategy must be identified to use the opportunities and overcome the challenges of electronic nursing documentation and be provided a successful implementation of a new information technology with appropriate design and integration technical, human and structural factors.