Evaluating the Barriers to Point-of-Care Documentation for Nursing Staff

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Point-of-care documentation has been identified as a patient safety measure for improving accuracy and timeliness of data. To evaluate the barriers that nurses and nurse aide/clinical technicians encounter for electronic point-of-care documentation, we conducted surveys on a telemetry unit at a southwestern Pennsylvania community hospital. Our first survey revealed that the location of the in-room computers, perceived lack of in-room computer reliability, Health Insurance Portability and Accountability Act/privacy concerns, and perceptions of the patients’ response to charting on computers in patient rooms were all barriers to point-of-care documentation. Our second survey revealed that workflow priority issues were also a barrier to point-of-care documentation, as staff members did not rate documentation as a high priority in terms of delivering timely medical care. Changes in both nursing practices and hospital infrastructure may be needed if these barriers to point-of-care documentation are to be overcome.

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