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Assessing usability of an electronic medical record is useful for organizations wishing to customize their electronic medical record and determine the impact on usability. The purpose of this article is to describe the development of a protocol to measure electronic medical record usability from a nursing perspective and to develop a scoring methodology. The Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records (NISTIR 7804), published by the National Institute of Standards and Technology, guided protocol development. Usability was determined by measuring effectiveness, efficiency, and satisfaction. Satisfaction was measured by the System Usability Scale, while effectiveness and efficiency were measured via performance testing by participants, who completed one of three scenarios. A protocol and scoring formula were developed and used to assess nursing usability, resulting in an overall "C" grade for the electronic medical record. Protocol implementation and the scoring/grading calculations can be replicated to assess electronic medical record usability. The three scenarios used in this protocol will be made available upon request from the primary author to promote the use of electronic medical record usability assessment. Using and expanding upon the government's recommended usability assessment guidelines, we were successful in measuring nursing electronic medical record usability and rating an electronic medical record.
This article was published in the following journal.
Name: Computers, informatics, nursing : CIN
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Individuals professionally qualified in the management of patients' records. Duties may include planning, designing, and managing systems for patient administrative and clinical data, as well as patient medical records. The concept includes medical record technicians.
Schedules of medical and nursing procedures, including diagnostic tests, medications, and consultations designed to effect an efficient, coordinated program of treatment. (From Mosby's Medical, Nursing & Allied Health Dictionary, 4th ed)
The area of nursing concerned with the needs and care of adult medical and surgical patients.
The use of electronic equipment to observe or record physiologic processes while the patient undergoes normal daily activities.
The creation and maintenance of medical and vital records in multiple institutions in a manner that will facilitate the combined use of the records of identified individuals.