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From Paper Forms to Electronic Flowsheets: Documenting Medical Resuscitations in a Time of Transition
Book chapter

From Paper Forms to Electronic Flowsheets: Documenting Medical Resuscitations in a Time of Transition

Swathi Jagannath, Aleksandra Sarcevic and Sage Myers
Information in Contemporary Society, pp 718-724
13 Mar 2019
DOI: https://doi.org/10.1007/978-3-030-15742-5_68

Abstract

Emergency medicine Nursing documentation Information behavior Workarounds Observations Electronic Health Records Interviews
Electronic Health Records (EHRs) have a critical role in supporting continuity of patient care and effective clinical decision-making. Although EHRs are widespread today, many emergency departments (EDs) have been slow in adopting them for documenting time-critical scenarios such as resuscitations. Introduction of an electronic flowsheet for documenting medical resuscitations at our research site provided a unique opportunity for studying the nuances of the transition from paper to electronic documentation. We observed 44 medical resuscitations and conducted post-event interviews with 24 nurse documenters to examine their interactions and behaviors with the newly implemented electronic flowsheet. While our findings showed many advantages of electronic documentation, such as improved access to patient records and auto-population of flowsheet sections, we also identified several challenges associated with the flowsheet navigation, technical issues, and lack of practice and use opportunities. We observed different workarounds used by nurse documenters to overcome these challenges, including the use of paper-based mechanisms, free-text fields, and simultaneous documentation by two nurses. Based on our findings, we provide design guidelines for improving the electronic flowsheet to support its use during resuscitations.

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