The computer-based patient record: A critical ethnography

Abstract

Within the evolving development work for the computer-based patient record, no consensus or research-based definition and description of the computer-based patient record has emerged as the standard. Nurses, as the creators and custodians of the patient health record, have long been hidden, unrecognized healthcare information managers. These two issues are addressed in this critical ethnography which revealed how seven registered nurses in clinical practice described the concept of the computer-based patient record. Each nurse worked in a different unit within one community healthcare enterprise and provided their insight through personal interviews and a personal drawing depicting their graphic representation of the concept of the computer-based patient record. Initial extensive document review and participant observation activities within the suburban healthcare facility helped frame the context for the research. Although each participant used the hospital information system daily, most of the nurses had not heard of or thought about the computer-based patient record. The nurses identified their initial concept of the computer-based patient record as being easily accessed patient information reflecting total patient care, no written record, and computers, especially those found at the bedside. Through their stories, details and recurrent themes emerged about the importance of infrastructure, information content, always maintaining the patient perspective, context, work processes, and support for nursing practice. The Bickford Model, developed as the guiding framework for the study, represented the relationships of time, context, information, person, and computer, and also identified the computer-based patient record as a subset of computer-based information.