As healthcare systems forge ahead with the implementation of electronic records (includes electronic patient/medical/health records), electronic clinical documentation is replacing paper-based documentation practices. Numerous benefits have been anticipated with ‘point of care’ or ‘point of service’ (POC/POS) systems, where clinical documentation systems are the most commonly used application in health care settings [9, 10]. Electronic nursing documentation at the POS has been recognized to improve both patient care and nurse experience by facilitating nursing productivity with documentation, eliminating redundancies and inaccuracies of charted information, improving timely access to data/information, and expediting interprofessional team communications [9, 11]. In addition, the ‘quality’ of completeness in electronic nursing notes has been demonstrated to improve the effectiveness and quality of the nursing visit from both a patient and nursing perspective [12].

Many assume that transitioning to electronic documentation practices automatically equates with success in achieving the intended roles of nursing documentation at the patient-client, organizational-departmental, and/or health system levels. Specifically, assumptions relate to documentation being able to: convey the quality of service/care provided, advocate patient-client preferences, facilitate ‘seamless’ care coordination by the interprofessional team, meet professional accountability requirements, and so forth. Table 8.2 highlights the aforementioned intended roles of effective electronic nursing documentation systems as a multidimensional communication tool at each dimension (i.e., patient-client, organizational-departmental and health system levels) with select practices/processes and aligned outcomes.

However, the success of achieving the intended roles with electronic clinical documentation systems involves a number of other considerations that will influence its success. Factors such as system design, system functionality, nursing computer proficiencies and nursing competencies (skills/knowledge) can result in both strengths and weaknesses in executing the process of nursing documentation. Effective design of electronic nursing documentation systems is a key consideration. The design of electronic nursing documentation system templates are critical if a ‘user friendly interface’ between the nurse and electronic documentation system will support clinician ‘usability’ as intended and successful adoption. Does the design of the electronic templates align with clinical assessment cognitive workflows? Specifically, does the data captured on the template align/resonate with the way clinicians think and document when performing patient/client clinical assessments, interventions, etc.? When electronic documentation applications fail to reflect or facilitate clinical practice (i.e. process) workflows or the priorities of clinicians for documentation, clinicians can develop some creative approaches (i.e. “workarounds”) to documenting the care provided despite the limitations of the application. Such “workarounds” will be created when electronic documentation applications do not reflect professional values or workflow [13]. Adler, Manager of Practice Standards describes Varpio’s system “workaround” phenomena as a “conflict” between the nurse and the electronic documentation system. Such conflicts arise when nurses cannot perform (document) adequately what is necessary to meet professional regulatory practice mandates ([14], p18).

System “workarounds” may be revealed when clinicians do not leverage the electronic tools as designed, which has consequences in achieving the intended benefits (e.g. improve patient safety, outcomes, team communications) when converting from paper to electronic nursing documentation. Workarounds may include not using the standard electronic template features (e.g. drop down menus, radio buttons) to select standard data elements in electronically documented nursing entries. Instead, nurses opt to document electronic assessments via text box entries or as text notes which mimics traditional paper based documentation processes and generates clinical data that is considered “unstructured” and not codified. The text note workarounds that model traditional paper-based documentation practices result in nursing data that is not readily available to be electronically ‘mined’ for analysis, losing one of the key advantages of electronic documentation tools. Here, relevant patient information at the point of care will not be easily accessible to the interdisciplinary team for timely, clinical decision-making. An additional consequence of text based workarounds impacts nursing productivity with timely nursing documentation and impacts the ability to clearly communicate the patient’s story and/or condition potentially affecting effective communications, patient safety and outcomes. To avoid these workaround pitfalls, Adler ([14], p18) indicates that contemporary regulatory standards of practice need to direct new nursing responsibilities/accountabilities with electronic documentation systems. Specifically, nurses must assume expanded advocacy roles in practice settings where involvement in choosing, implementing, and evaluating new electronic documentation systems is essential. Thus, documentation system design would more likely conform to practice policies and support quality nursing care ([14], p18). Further, active nursing participation in system selection, implementation and evaluation will facilitate successful adoption where the system features are leveraged as intended.

Documentation design surrounding content or data elements embedded in the electronic templates is a controversial topic. Numerous authors [13, 15] point out that the anticipated benefits of electronic clinical documentation may never be realized for those documentation applications developed without gaining an in-depth understanding of the use of paper-based documentation or the importance of oral and paper-based communications. Specifically, tensions can be created during electronic documentation design sessions between traditional professional practice leaders and nurse informaticians and/or clinical informaticians when data elements and content design decisions are being made. Such tensions can be even more pronounced when such design teams lack an informatics resource and the professional practice leaders are left to design system applications with only technical resources that lack any clinical knowledge or experience. Also, the tendency of many design teams is to duplicate existing paper documentation forms in the design/build of electronic documentation applications, which once implemented, are minimally used with limited documentation value. If efficiencies and successes of documentation benefits are to be realized, then conversion from paper-based documentation tools to electronic documentation (eDoc) must be recognized as more than mere replication of paper forms into an electronic format [16, 17]. To avoid the latter content design pitfalls and ensure that key episodic or unresolved patient issue data is “surfaced” for quick identification and follow up, it would benefit organizations to understand, value, and embrace the role of skilled nurse informatician (NI) resources to lead, partner, and guide documentation system design decisions with professional practice and technical resources. Healthcare trends leveraging NI resources are demonstrating successful system designs and implementations [8, 18].

Electronic documentation design that incorporates recognized/approved standardized nursing languages (e.g. ICNP – International Classification of Nursing Practice, C- HOBIC – Canadian Health Outcomes for Better Information and Care) enables nurses to more easily access, search, and view relevant interpretable patient information to make informed care decisions across the inter professional team. See Chap, 7 for a more in depth discussion of standards and standardized nursing languages. Enabling clear, succinct, and legible electronic documentation reduces the risk of misunderstanding, and improves patient outcomes as a result of effective communications [2].

Extending the use of standardized nursing languages in electronic nursing documentation tools across jurisdictions (i.e., in electronic health records) has the potential to generate health system level benefits from three perspectives. First, it facilitates patient centred care, as relevant health information follows the patient/client and is accessible across the continuum of care wherever care is provided. Patients/clients are no longer required to rely on memory for sharing important information (e.g. allergies, medications, etc.), and this enables consistent, accurate information that is captured once and used many times. Second, use of standardized languages demonstrates nursing professional practice’s accountability in the delivery of care and third, it enhances the ‘visibility’ of nursing’s contributions through electronic documentation. With nursing standardized languages embedded in electronic documentation tools, nurses can be freed up to focus on their work, and data can be captured demonstrating nursing’s effectiveness, contributions and accountability. This also supports accurately attributing nursing actions and outcomes to nursing rather than to other professions, and enables accurate cost analysis of nursing [3, 19]. Without standardized languages embedded in electronic documentation tools, nursing will never realize the advantages of the EHR at the system level, namely having relevant patient information at the point of care, real-time decision support, and or computer generated nursing data that is evidenced-based [20].

This next section presents some of the common clinical or nursing documentation applications. Nurses, depending on their practice setting will encounter a variety of solutions in acute care, community health and public health. It is important to note that clinical applications are distinct in terms of their functionality and interfaces and are designed to support the specific clinical needs (or business needs) of the domain in which they are used. Although there are many vendors and applications available, it is beyond the scope of this text to include all possible options.

The following examples are presented as known credible documentation applications and no endorsement over other applications is intended by their inclusion.