THE IMPACT OF UTILIZING AN ELECTRONIC MEDICAL RECORD IN THE ENTRY-LEVEL NURSING SIMULATION LAB ON THE QUANTITY AND QUALITY OF STUDENT DOCUME

Objective. The purpose of this study was to determine if the use of the electronic medical record (EMR) in the simulation lab increased the student’s documentation tendency. The primary focus was to determine if there would be an increase in the quantity and quality of documentation for the simulated patients’ medical record by students participating in a simulated clinical experience. Background. Documentation in the medical record provides a basis for communication with the health care team. Professional nurses must have the ability to communicate effectively in the medical record to convey patient status to other health care team members. The introduction of the EMR has facilitated access and communication. Education of nursing students in regards to the EMR is necessary for optimal progression into clinical practice. Methods. A nonexperimental descriptive study was used to audit data obtained from entry level nursing students’ documentation in simulation learning experiences. Results. The findings determined that an educational EMR slightly increased documentation but, the incorporation of a teaching EMR (alone, without a bar code system) did not statistically significantly close the gap of the documentation deficiency and that further educational interventions are required. Conclusion. Utilization of an education EMR marginally increased student documentation in the simulation setting. Grants. None