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Documentation, Electronic medical record system, Technology, Undergraduate nursing



  1. Holland, Cindra DNP, RNC-OB, C-EFM, ACNS-BC
  2. Stuber, Marlene MS, RN, CHSE
  3. Mellon, Molly MS, RN, ONC, CHSE


Over the past 15 years, the use of electronic medical record systems in the healthcare setting has grown exponentially. Accurate input of patient data is critical to facilitate safe care and effective communication among all members of the healthcare team. To keep pace with the practice environment, nursing students must have the opportunity to document health-related information in an electronic medical record early in the educational program. The purpose of this project was to create a cost-effective electronic medical record system for undergraduate nursing students to learn appropriate documentation of patient-related findings. Patient-centered care, informatics, and safety were the focus topics from the Quality and Safety Education for Nurses project included in the development of this endeavor. Faculty worked in collaboration with the university's information technology department to develop an innovative electronic medical record to be used in physical assessment, which is the first course in the nursing curriculum. Positive feedback was obtained from students and faculty about the project. It is important to provide students with the opportunity to experience electronic documentation to effectively prepare them for the ever-changing practice environment.