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A recent addition to the health care landscape is the electronic health record. With this technology moving to the bedside, more assessments and patient data are inputted by the nurse, at the point of care. Little is known about the impact point-of-care electronic documentation has on the patient experience. A qualitative research design was used to explore the hospitalized adult patient's experience during point-of-care electronic documentation. One-onone, semi-structured, in-depth interviews were conducted; interview data were transcribed verbatim and analyzed using thematic content analysis. Study findings were incorporated into developing a four-stage process for clinicians to use during point-of-care electronic documentation.
Patient satisfaction has increasingly become an important outcome measure in evaluating the quality of care services provided to patients. Milutinovic', Simin, Brkic', and Brkic' (2012) noted that patient satisfaction with nursing care "is the most important predictor of patients' overall satisfaction with their hospital care" (p. 598). Patient satisfaction has been described as the response a patient has to his/her health care experience "in relation to particular aspects of care, such as nursing and medical care or admission and discharge processes" (Laschinger, Gilbert, & Smith, 2011, p. 360). When a patient's expectations are not met, the patient's satisfaction with care diminishes (Iftikar et al., 2011).
Background and Purpose
With the introduction of the electronic health record (EHR), more clinical documentation is done at the point of care: the patient's bedside. The utilization of the EHR as a pointof-care electronic documentation (POCED) tool has been noted in the medical literature as having several benefits. These include that it: (a) facilitates timely clinical decision making and the anticipation of care needs; (b) makes possible shared communication, reduces errors, and prevents duplicate/ redundant tests from being ordered; (c) streamlines inefficiencies; (d) facilitates the transfer of information; (e) provides for the simultaneous viewing of up-to-date information by multiple care providers; (f) facilitates speed in care delivery; (g) promotes the clinician spending time with the patient at the bedside as they document care; (h) increases the quality and compliance of documentation while decreasing variation; and (i) provides the ability to access internet resources for care delivery and for patient education (Duffy & Kharasch, 2010; Liu, Luo, Zhang, & Huang, 2013; Swinglehurst, Roberts, & Greenhalgh, 2011; Ventres et al., 2006).