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There is a little evidence of the impact of clinical information system implementation on nurses' workflow and patient care to guide institutions across the nation as they implement electronic health records. This study compared changes in nurse's perceptions about patient care processes and workflow before and after a comprehensive clinical information system implementation at a rural referral hospital. The study used the Information Systems Expectations and Experiences survey, which consists of seven scales-provider-patient communication, interprovider communication, interorganizational communication, work-life changes, improved care, support and resources, and patient care processes. Survey responses were examined across three administrations-before and after training and after implementation. The survey responses decreased significantly for eight of the 47 survey items from the first administration to the second and for 37 items from the second administration to the third. Perceptions were more positive in nurses who had previous experience with electronic health records and less positive in nurses with more years of work experience. These findings point to the importance of setting realistic expectations, assessing user perceptions throughout the implementation process, designing training to meet the needs of the end user, and adapting training and implementation processes to support nurses who have concerns.