Barriers nurses face as they transition from paper to electronic charting, as described by Kunz (2010), were the logon and logoff process, dead computer batteries, missing power cords, misplaced laptops, resistance to change, and time management. On the other hand, Berner (2008) explained challenges encountered from using electronic systems, according to the general agreement of informatics experts, is not the system perse, but the faulty implementation, inadequate training, poor system design, and inadequate evaluation of the system prior to widespread use. It would be reasonable to assume that if these barriers were to be addressed prior to implementing EHR systems, it would improve the use of these computerized systems. Whether charting using paper-based or EHR, taking a blasé attitude towards documentation is a sure way for a nurse to endanger their license; especially when an adverse action happens.

Benefits Using EHR

Bergmann (2012) described some of the benefits transferring from paper-based charting to using an EHR system as improvement in legibility, storing and retrieval of patient information, increased organization, and accessibility of information. From my personal experience, using EHRs decreased errors caused by reading progress notes, deciphering orders, and understanding of other health-related information was improved. The impact that computerization made within the healthcare industry is evident; however, the advent of systems of this nature lead to a genesis of a variety of other issues such as ethical and legal ramifications.

Ethical Issues

Some of the ethical issues erupting from the introduction of EHR systems include obtaining informed consent, protecting privacy, ensuring confidentiality, and respecting the safety and dignity of patients (Hicks, 2011). For example, if there is a breach in privacy and security of an EHR system and patient health information, patients can suffer from an assortment of damages such as a stolen credit card numbers, identity theft from stolen social security numbers, or emotional harm if personal information is disclosed. It has been noted in the literature that several vendors have sold decoded copies of patient databases to pharmaceutical companies, medical device makers, and health service researchers. The problem is that decoded data sets can be re-associated with patients, thus creating a breach in patient personal health information. In other words, there is a need to balance the benefits versus the potential risks of using EHR systems when applying interventions to improve patient safety and quality of care.

Legal Considerations

A major responsibility as a provider is to keep accurate and complete patient medical records while bearing in mind that recorded information is sensitive information. Issues and concerns of using computers in the medical field focus on privacy and confidentiality rights of patients. Knowing which portion of the record may be called for review in a court trial allows nurses to increase proficiency in their documentation. The newer areas of confidentiality concern computer documentation, electronic resources, and the multiple applications of HIPAA. Some tips for effective documentation are to make an entry for every observation, follow- up as needed, read nurse notes before giving care, make an entry even if it is late, make the chart entry after the event, use clear and objective language, and be realistic and factual (Guido, 2006). It is important to note that charting by exception is not without legal ramification. This type of charting may fail to give enough information to alert providers to problems. Also, charting of this nature does not convey the attentiveness of the nursing staff to patients; especially patients in whom complications develop.

Strategies for Implementing an EHR

Choosing an EHR system is a big decision. Doing the legwork and taking charge to implement a strategic approach will position organizations for long-term success and enhanced patient care. Putting clinical and operational improvements first, while also recognizing the importance of utilizing technology, is a win-win strategic approach to implementing an EHR system. Mathews (n.d) advises that in doing the research the proper steps to take are to first identify and narrow the vendors, then involve a sampling of hospital employees from different departments to determine what will effectively meet the needs of those departments. Additionally, tapping into the resources of staff members with fast, real-world problem-solving skills is essential to the successful implementation of an EHR system. It only makes sense that addressing barriers prior to implementation of an EHR system will improve patient care and the use of the system.

It is also important for an organization not to rush implementing an EHR system or follow a cookie cutter system of implementing an EHR system as each facility has a different set of values, priorities, culture, and resources. Instead, it is critical that an organization take the time to get staff members onboard for this major change; especially the end users of the system. Protecting patient information by ensuring staff members have facts about the legal and ethical ramifications of a HIPAA violation will help in preventing untoward situations. Having experienced the transition from a paper-based system to an EHR system, which did not take a strategic approach to implementation, this author can state that negative effects were still present years afterward.

When incorporating a major change in practice, such as with the introduction of an EHR system, engaging frontline workers, especially frequent users of the system, and ensuring they understand the big picture is important. Nurses need to realize the benefits of using computerized charting in order to improve the documentation process and understand how the process can be made easier, more efficient, and more effective. Training should not stop after implementation of the system but should be done incrementally to ensure staff members are maintaining their knowledge and skill in using the system properly. Lewin’s plan change theory is one of many change theories that can prove invaluable when aligning staff towards a common goal to increase success for change.


A nurse’s conscience when documenting and caring for patients reflects the professional and personal caregiver the nurse truly is. A nurse, at any given moment in time, should know doing the right thing is the only thing to do. EHR has advanced as a mechanism for transforming nursing care, enabling nurses to function as knowledge workers, having the potential of making nursing care less stressful, more satisfying, more research-based, and more visible. Paper-based charting will soon be a part of nursing history. Failure to embrace the digital age will set nurses behind their peers and other medical staff.


Bergmann, B. B. (2012). An exploratory study of EHR system usability (master’s thesis). Retrieved from ProQuest Dissertations and Theses. (1266830320).

Berner, E. S. (2008). Ethical and legal issues in the use of health information technology to improve patient safety. HEC Forum, 20(3), 243-58. doi: 10.1007/s10730-008-9074-5

Guido, G. W. (2006). Legal & ethical issues in nursing. (5 ed.). Upper Saddle River, NJ: Prentice Hall.

Hicks, L. (2011). Informed consent – SBR. Retrieved from 0F49-4DC7-A89F-091A7B6630C8-14468294&module=504

Kunz, M. G. (2010). Embracing the electronic medical record. Nursing for Women’s Health (14)4, 290-300. doi: 10.1111/j.1751-486X.2010.01559.x

Mahler, C., Ammenwerth, E., Wagner, A., Tautz, A., Happek, T., Hoppe, B., & Eichstädter, R. (2007). Effects of computer-based nursing documentation system on the quality of nursing documentation. Journal of Medical Systems(31)4, 274-282. doi: 10.1007/s10916- 007-9065-0

Leave a Reply