Purpose/Objectives:

Most healthcare organizations are transitioning to an electronic medical record. Implementing these systems is resource intensive. Nursing is vital in the development of these systems that support best practice rather than dictate practice. Processes must change and support nursing practice during this transition.

Significance:

Nursing at a major medical center was involved during the transition to an electronic record and continues to be involved in all aspects of the design, build, implementation, device selection, training, and communication. A clinical nurse specialist (CNS) was identified by leadership to assist with the integration and development of this system by bridging the gap between the information technology teams and clinical practice.

Design/Background/Rationale:

The CNS as the nurse liaison helped bring together the individual talents of all members of the team including nursing, information technologists, pharmacists, respiratory therapists, and others. The teams were challenged by the integration of other electronic systems including the use of bar coding, physician order entry, electronic medication administration records, and patient data.

Methods/Description:

Integrating information technology in order to create a seamless system was imperative for safe patient care. Implementing an electronic medical record offered an opportunity to redefine how nursing practice is articulated and reflected in the electronic health record. As end users, nurses helped drive this process and assisted in integrating these systems to improve patient safety.

Findings/Outcomes:

The CNS with an interest in how technology affects nursing practice and patient care had a unique opportunity to improve nursing practice and the work environment through the creative use of technology.

Conclusions:

The CNS assisted in developing processes that were effective and meaningful for the transition to an electronic documentation system.

Implications for Practice:

Implementation of an electronic medical record is ongoing and challenging. Nursing must be involved with all steps of the process.

Section Description

The journal is proud to share the student abstracts accepted for poster presentation at the 2009 National Association of Clinical Nurse Specialists Conference. These abstracts are submitted under a separate later deadline and therefore did not appear in the journal with the general abstracts. Congratulations to these CNS students and their faculty mentors.