Can compassionate care be documented in the electronic medical record

AIM: The aim of this study was to evaluate the ability of the electronic medical record to document compassionate care behaviors.;BACKGROUND: A review of the literature reveals that compassionate care promotes patient satisfaction and promotes healing. Subsequently, it can play a role in the reduction of health care costs.;METHODS: Three fictitious case studies containing compassionate care behaviors were developed and validated by three experts. Researcher assistants were then asked to document the case studies into electronic medical records at three local hospitals.;RESULTS: None of the hospital's EMR systems were able to completely capture compassionate care behaviors using the current `build" of the system. Therefore, the majority of documentation had to occur in free text. Using the current structures, word loss from the current systems ranged between 5% and 100%. Whereas normal handwritten documentation could occur in one page, the computer generated printouts from the EMR systems ranged from a low of 2 pages to a high of 14 pages. Compared to structured entries, the abundance of free text entries would be prohibitive for rapid data extraction.;IMPLICATIONS: EMR systems should be redesigned to include additional structure through drop down boxes and "smart text" that would allow for nurses to easily document compassionate care behaviors. This would enhance the ability of the hospital to provide data supporting the ability to increase patient satisfaction by demonstrating evidence of compassionate care given by the staff.