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.