Ruth Everett-Thomas1, Laly Joseph2, Gloria Trujillo3. 1. University of Miami School of Nursing & Health Studies, 5030 Brunson Drive, Suite 225, Coral Gables, FL 33147, United States of America. Electronic address: reverett@miami.edu. 2. Phillips School of Nursing at Mount Sinai Beth Israel, 776A Sixth Avenue, Suite 4A, New York, NY 10001, United States of America. Electronic address: laly.joseph@mountsinai.org. 3. University of Miami School of Nursing & Health Studies, 5030 Brunson Drive, Coral Gables, FL 33147, United States of America. Electronic address: g.trujillo@miami.edu.
Abstract
INTRODUCTION: Electronic health records have become a standard documentation platform to house patient information in most US hospitals. To improve documentation, providers suggest establishing electronic health record user education at the classroom level so students can interact with patient data early. The purpose of this study was to assess student nurses' clinical documentation and critical thinking skills using virtual patients and a simulated electronic health record system. METHODS: Eighty-four undergraduate nursing students completed assessments on four assigned virtual patients and entered their findings into a simulated electronic health record system. Benner's five stage novice to expert theory was used to evaluate performance of six assessment items. RESULTS: Significant differences (p = 0.046) were seen in median scores between the first and second assignments, and between the second and fourth assignments (p = 0.021) with minimal improvements from one assignment to the next. DISCUSSION: Data entered in the electronic health record showed that students started at an advance beginner's level and moved to be proficient in documenting basic patient information using critical thinking skills by the end of the first semester. CONCLUSION: It is important to expose students to electronic health record systems before entering the workforce or while training in a hospital setting to enhance readiness for clinical practice with electronic documentation and critical thinking skills.
INTRODUCTION: Electronic health records have become a standard documentation platform to house patient information in most US hospitals. To improve documentation, providers suggest establishing electronic health record user education at the classroom level so students can interact with patient data early. The purpose of this study was to assess student nurses' clinical documentation and critical thinking skills using virtual patients and a simulated electronic health record system. METHODS: Eighty-four undergraduate nursing students completed assessments on four assigned virtual patients and entered their findings into a simulated electronic health record system. Benner's five stage novice to expert theory was used to evaluate performance of six assessment items. RESULTS: Significant differences (p = 0.046) were seen in median scores between the first and second assignments, and between the second and fourth assignments (p = 0.021) with minimal improvements from one assignment to the next. DISCUSSION: Data entered in the electronic health record showed that students started at an advance beginner's level and moved to be proficient in documenting basic patient information using critical thinking skills by the end of the first semester. CONCLUSION: It is important to expose students to electronic health record systems before entering the workforce or while training in a hospital setting to enhance readiness for clinical practice with electronic documentation and critical thinking skills.