Abstract
Electronic health records have become a standard documentation platform to house patient information in most US hospitals. To improve documentation, providers suggest establishing electronic health record user education at the classroom level so students can interact with patient data early. The purpose of this study was to assess student nurses' clinical documentation and critical thinking skills using virtual patients and a simulated electronic health record system.
Eighty-four undergraduate nursing students completed assessments on four assigned virtual patients and entered their findings into a simulated electronic health record system. Benner's five stage novice to expert theory was used to evaluate performance of six assessment items.
Significant differences (p = 0.046) were seen in median scores between the first and second assignments, and between the second and fourth assignments (p = 0.021) with minimal improvements from one assignment to the next.
Data entered in the electronic health record showed that students started at an advance beginner's level and moved to be proficient in documenting basic patient information using critical thinking skills by the end of the first semester.
It is important to expose students to electronic health record systems before entering the workforce or while training in a hospital setting to enhance readiness for clinical practice with electronic documentation and critical thinking skills.
•Using electronic health records early in training may prevent mistakes in patient's medical records.•Safe environments that allow student nurses to practice inputting data into a simulated system may be beneficial.•Student nurses may improve their nursing assessment skills and knowledge when using virtual patients.•Benner’s model can be used to assess student nurse’s skills level for data input using two simulation platforms.
