THE ROLE OF ELECTRONIC NURSING DOCUMENTATION IN ENHANCING PATIENT CARE QUALITY: A SYSTEMATIC LITERATURE REVIEW

Siska Mayang Sari; Faridah Mohd Said

doi:10.53625/ijss.v5i3.11480

Authors

Siska Mayang Sari Faculty of Nursing Lincoln University Collage
Faridah Mohd Said Faculty of Nursing Lincoln University Collage, Malaysia

DOI:

https://doi.org/10.53625/ijss.v5i3.11480

Keywords:

Electronic Nursing Documentation, Quality of Care, Systematic Literature Review

Abstract

Electronic nursing documentation (END) has become an essential component of modern nursing practice. The use of END is expected to improve the quality of patient care through more accurate and efficient record keeping. This article aims to evaluate the effectiveness of electronic nursing documentation in improving the quality of patient care. This systematic review study was conducted in June-July 2024 by searching the literature on electronic databases such as ProQuest, Science Direct, PubMed, and Google Scholar for articles published between 2019 and 2024. The keywords used included “electronic nursing documentation”, or “computerized nursing documentation” and “quality of care” and “nurse” “hospital”. Two reviewers independently screened the articles, extracted data, and assessed the quality of the included studies using the Systematic Reviews and Meta-Analyses (PRISMA). There were 9 articles met the inclusion criteria and were analysed further. The inclusion criteria were RCT and non RCT, cross sectional and observational study, and hospital setting, while the exclusion criteria were qualitative study and literature or systematic review. The analysis showed that the use of END significantly improved the quality of nursing care, enhanced communication and collaboration among healthcare providers, leading to improved patient outcomes. Besides, END improved documentation accuracy, time efficiency, operational efficiency, error reduction and patient safety. However, some challenges such as monitoring and evaluation from nurse managers regarding the accuracy and quality of documentation and the need for computer skills training are also needed. It Concluded the electronic nursing documentation has great potential to improve the quality of patient care in hospitals

References

Adnan, L. A. (2023). Electronic Nursing Documentation Interventions to Promote or Improve Patient Safety and / or Quality Care in an Acute Settings : Rapid Review. International Journal of Health Science, 7(3), 154–164. https://doi.org/10.53730/ijhs.v7nS1.14313

D’Agostino, F., Zeffiro, V., Cocchieri, A., Vanalli, M., Ausili, D., Vellone, E., Zega, M., & Alvaro, R. (2019). Impact of an Electronic Nursing Documentation System on the Nursing Process Accuracy BT - Methodologies and Intelligent Systems for Technology Enhanced Learning, 8th International Conference (T. Di Mascio, P. Vittorini, R. Gennari, F. De la Prieta, S. Rodríguez, M. Temperini, R. Azambuja Silveira, E. Popescu, & L. Lancia (eds.); pp. 247–252). Springer International Publishing.

Dinari, F., Mashouf, E., Bahaadinbeigy, K., Bassiri, S., Bastaminejad, S., & Moulaei, K. (2023). Benefits , barriers , and facilitators of using speech recognition technology in nursing documentation and reporting : A cross ‐ sectional study. Health Science Reports, January, 1–13. https://doi.org/10.1002/hsr2.1330

Gaudet, C. A. (2016). Electronic Documentation and Nurse-Patient Interaction. Advances in Nursing Science, 39(1), 3–14. https://doi.org/10.1097/ans.0000000000000098

Groot, K. D., Veer, A. J. E. d., Munster, A. M., Francké, A. L., & Paans, W. (2022). Nursing Documentation and Its Relationship With Perceived Nursing Workload: A Mixed-Methods Study Among Community Nurses. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-00811-7

Halimatussakdiah, H., Faisal, T. I., Nuraskin, C. A., & Ahmad, A. (2022). The Effect of Electronic Nursing Documentation ( END ) Implementation on Nursing Services Toward Patients ’ Satisfaction. Jurnal Aisyah Jurnal Ilmu Kesehatan, 7(1), 1–10. https://doi.org/10.30604/jika.v7i1.842

Hussein, S. Z., Khalip, N., Hashim, R., Harun, R., & Fazilah, N. F. (2021). Patient Care Delivery : Electronic Nursing Documentation in Malaysia Patient Care Delivery : Electronic Nursing Documentation in Malaysia. Makara Journal of Health Science, 25(2), 101–106. https://doi.org/10.7454/msk.v25i2.1288

Karp, E. L., Freeman, R., Simpson, K. N., & Simpson, A. N. (2019). Changes in Efficiency and Quality of Nursing Electronic Health Record Documentation after Implementation of an Admission Patient History Essential Data Set. CIN - Computers Informatics Nursing, 37(5), 260–265. https://doi.org/10.1097/CIN.0000000000000516

Kodama, K., Konishi, S., Manabe, S., Okada, K., Yamaguchi, J., Wada, S., Sugimoto, K., Itoh, S., Takahashi, D., Kawasaki, R., Matsumura, Y., & Takeda, T. (2023). Impact of an Electronic Medical Record–Connected Questionnaire on Efficient Nursing Documentation: Usability and Efficacy Study. JMIR Nursing, 6, e51303. https://doi.org/10.2196/51303

Pure, D. V, Ambad, R., Kaple, M., & Dighade, R. . (2022). A Review on Association between Electronic Health Record use and Quality of Patient Care. Journal of Datta Meghe Institute of Medical Sciences University |, 457–460. https://doi.org/10.4103/jdmimsu.jdmimsu

Pyron, L., & Carterleton, H. (2019). Improved Patient Flow and Provider Efficiency after the Implementation of an Electronic Health Record. CIN - Computers Informatics Nursing, 37(10), 513–521. https://doi.org/10.1097/CIN.0000000000000553

Riaz, S., Nazir, S., Zia, T., Yasmeen, T., Shoukat, S., & Latif, W. (2022). Knowledge and Perception of Electronic Health Record Among Nurses. PJMHS, 16(7), 82–84. https://doi.org/10.53350/pjmhs2216782

Saranto, K., Kinnunen, U., Kivekäs, E., Lappalainen, A.-M., Liljamo, P., Rajalahti, E., & Hyppönen, H. (2013). Impacts of Structuring Nursing Records: A Systematic Review. Scandinavian Journal of Caring Sciences, 28(4), 629–647. https://doi.org/10.1111/scs.12094

Vehko, T., Hyppönen, H., Puttonen, S., Kujala, S., Ketola, E., Tuukkanen, J., Aalto, A. M., & Heponiemi, T. (2019). Experienced Time Pressure and Stress: Electronic Health Records Usability and Information Technology Competence Play a Role. BMC Medical Informatics and Decision Making, 19(1). https://doi.org/10.1186/s12911-019-0891-z

Wang, N., Yu, P., & Hailey, D. (2013). Description and Comparison of Documentation of Nursing Assessment Between Paper-Based and Electronic Systems in Australian Aged Care Homes. International Journal of Medical Informatics, 82(9), 789–797. https://doi.org/10.1016/j.ijmedinf.2013.05.002