Interdisciplinary collaboration and the electronic medical record.
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PURPOSE
To examine interdisciplinary collaboration via electronic medical records (EMRs) with a focus on physicians' perception of nursing documentation.
DESIGN
Quality improvement project using a survey instrument.
LOCATION
Tertiary care pediatric hospital.
PARTICIPANTS
Thirty-seven physicians.
OUTCOME MEASURE
Physicians perceptions of nursing documentation after EMR implementation
KEY FINDINGS
Physicians desire nursing documentation with greater clarity and additional information. Physicians indicate checklists alone for patient assessment and intervention data are insufficient for effective nurse/physician collaboration. Narrative nursing summaries are invaluable references that guide medical treatment decisions. Physicians see detailed assessments and well-described interventions of nurses' as critical to their ability to effectively practice medicine.
KEY CONCLUSIONS
Health care technology is called to develop EMRs that enable nurses to document detailed patient data in a swift and straightforward manner. Joint collaboration between nurses, physicians, and technology specialists is recommended to develop effective EMR systems.