Physicians' and Nurses' Documenting Practices and Implications for Electronic Patient Record Design

Data entry is still one of the most challenging bottlenecks of electronic patient record (EPR) use. Today's systems obviously neglect the professionals' practices due to the rigidity of the electronic forms. For example, adding annotations is not supported in a suitable way. The aim of our study was to understand the physicians' and nurses' practices when recording information in a patient record. Based on the findings, we outline use cases under which all identified practices can be subsumed. A system that implements these use cases should show a considerably improved acceptance among professionals.