Electronic Nursing Documentation Research Articles

A systematic review of the implementation of electronic nursing documentation toward patient safety

We find out the implementation of electronic nursing documentation toward patient safety. A systematic review of 15 articles were using PRISMA from five online database: Science Direct, ProQuest, Scopus, Wiley Online, and Emerald Insight. The keywords used are "nursing documentation," "electronic health record," and "patient safety). The implementation of EHR has an effect on patient safety i.e. improving identify patients correctly, improve effective communication, improve the safety of high-alert medications, ensuring the correct location of surgery, and reducing the risk of infection. In addition, it also reduces the risk of patient injury due to falls by helping with falling risk screening process. Optimizing the implementation of electronic nursing documentation affects the quality of nursing documentation and patient safety. The result of this study may impact nursing managers while improving integrated EHR with nursing documentation.

Implementation of Effective Nurse Communication in Hospital Through Electronic Nursing Documentation (END)

Introduction: The low quality of documented information becomes the main cause of failure in conductingeffective communication. The implementation of electronic nursing documentation improves the quality ofinformation so that it facilitates the implementation of effective communication. Objective: To identify theimplementation of effective communication of nurses in hospitals through electronic nursing documentation.Method: A cross sectional design with 243 nurses as total sample. The effective communication instrumentconsists of 52 statements. The validity test result is in the range of 0.396-0.946 and the reliability testresult is Cronbach’s alpha 0.965. The data are collected online using Google form application. Results:Implementation of effective communication of nurses was 80.18% of the maximum value. The highesteffective communication occurred on patient discharge while the lowest conducted in receiving messages byphone. The implementation of effective communication during the nursing process is 78.70%. Conclusion:The implementation of electronic nursing documentation could facilitate the implementation of effectivecommunication for nurses in hospitals. However, effective communication during the nursing process ispotentially requiring more improvement. The recommendation is that the nursing manager should encouragethe implementation of effective communication through the utilization of electronic nursing documentation.

The effect of early adoption of an academic electronic health record system in nursing education: A pilot outcome study

Objective: This study aimed to explore the faculty’s and students’ perceptions of an academic electronic health record system (AEHRs) for teaching/learning electronic nursing documentation and to assess the outcomes of the AEHRs on nursing students’ competency with electronic nursing documentation.Methods: With a mixed-method pilot study, a convenience sample of 41 undergraduate nursing students and a purposive sample of 7 faculty and 9 students were used. Two groups of student participants for the quantitative data were compared for their competency with electronic nursing documentation. For the qualitative data, an in-depth, exploratory approach to data collection was taken for the nursing faculty and the intervention group.Results: For the quantitative findings, the early adoption of an AEHRs could help students to collect a patients’ health information through the system even though it may not impact their critical thinking on a patient’s care. For the qualitative findings, three key themes were shared by the faculty and students: (1) benefits and challenges, (2) impact of the AEHRs, and (3) recommendations for future adoption.Conclusions: This study revealed that the successful adoption of an AEHRs includes many steps that can be used to create positive improvements. These findings were beneficial to prepare students and nursing educators for the future of health information technology. Meaningful adoption of an AEHRs will help in building the competence of undergraduate nursing students in electronic nursing documentation and improve patient care.

Description and Validation of Nursing Diagnosis Using Electronic Documentation: Study Cases in Mother and Child Hospital Indonesia

Background: A nursing diagnosis is a clinical judgment concerning a human response to a health condition, vulnerability for that response, by an individual, family, group, or community. For the determination of the right nursing diagnosis, a system that guides nurses in implementing care professionally is needed. Objective: To describe the nursing diagnosis in mother and child cases validated by using a management nursing information system. Methods: This case study used secondary data from 5.294 medical records. Medical records were retrieved from the server, analyzed, and validated by using the mapping model in accordance with the most frequent cases in mothers and children in the hospital. Approximately ten million (10.021) nursing diagnoses were performed by nurses and validated by using a mapping model of medical cases and nursing assessment. The selected medical cases were the five most frequent cases, namely normal delivery, cesarean delivery, healthy newborn, fever, and dengue in children. Results: This study yielded the five most frequent nursing diagnoses, namely risk for infection (20.1%), pain (13.37%), anxiety (9.37%), the risk for imbalanced fluid volume (9.36%), and risk for bleeding (9.27%). Conclusion: The electronic nursing documentation could help to determine a nursing diagnosis and had been validated for its appropriateness with assessment and the most common cases in mothers and children. Information and system training development are required to carry out the nursing process comprehensively.

Pengalaman Perawat dalam Penggunaan Rekam Medis Elektronik di Rumah Sakit Panti Rini Yogyakarta

Background: Nursing documentation through electronic medical records is expected to provide convenience for nurses.
 Purpose: explore nurses' experiences in using electronic medical records.
 Method: this study was a qualitative research, used purposive sampling technique. The research was conducted at Panti Rini Hospital Yogyakarta and conducted in May 2020 and interviewed 5 nurses and 1 head of the ward in the inpatient ward.
 Result: this study found 4 themes: 1) the use of electronic medical records to provide convenience, 2) supporting factors for the use of electronic medical partners, 3) obstacles in the use of electronic medical records 4) the expectations of nurses in using electronic medical records.
 Conclusion: the hospital needs to improve facilities and infrastructure so that the available system is able to accommodate the need for electronic nursing care documentation.

Implementation of an Electronic Nursing Record for Nursing Documentation and Communication of Patient Care Information in a Tertiary Teaching Hospital.

Despite the fact that implementing an electronic nursing record has become an everyday event for nurses, little is known about which type of documentation used in an electronic nursing record is better for nursing practice. The aim of this exploratory study was to identify the most suitable type of electronic nursing documentation that nurses used to record care and communicate with clinicians. Participants consisted of 118 nurses and 12 physicians. Researchers developed a self-report questionnaire of 17 items about electronic nursing record use for documentation and communication of patient care information. Data were analyzed using descriptive statistics to calculate frequencies and percentages. The χ2 test was used to identify differences in responses by demographic and clinical characteristics of participants. Bar charts were used to identify response patterns. Results showed that semistructured nursing documentation was the most preferred for care documentation and communication of patient information. Nurses did not always use the electronic nursing record to communicate patient care-related information. This study adds empirical knowledge about which type of documentation used in the electronic nursing record works well, what improvement is needed for better nursing practice, and whether the electronic nursing record has been used for communication.

Information Systems for Nursing Documentation

Introduction: Nursing documentation is an integral part of clinical documentation and is a fundamental responsibility of the nursing industry. However, the transition from handwritten to electronic nursing documentation is a challenge among healthcare professionals. Purpose: The main purpose of this study was to record basic issues related to the introduction and acceptance of electronic nursing documentation systems in healthcare. Method: The Greek and international literature is thoroughly studied on this subject and a case study on the obstacles to the introduction of such a system is presented in Erlangen, Germany. Literature review was performed using Google Scholar and PubMed electronic databases. Results: The perception of nurses and health service provider managers regarding electronic nursing documentation is the most important indicator for the adoption of such a model. However, for proper implementation it is necessary to cooperate among the members of the interdisciplinary health team, to constantly enrich nurse’s knowledge, to constantly check and evaluate staff, to systematic feedback to improve clinical practice, to understand the needs of the patients and compliance with the quality assurance criteria. Conclusions: Information and communication technologies have penetrated to a significant extent in the health sector. Therefore, studying the incentive and inhibitory factors in the adoption by health providers of an electronic nursing documentation system will provide important insight into how these systems are designed and how these systems are introduced to healthcare providers.

Pengembangan Dokumentasi Keperawatan Berbasis Elektronik Di RS X Kota Depok Dengan Menggunakan Teori Perubahan Lewins

Background: Nursing documentation in Indonesia is still much in the form of paper based documentation. Many weaknesses in this documentation model, so it needs to be innovated by using electronic-based nursing documentation. Problems that occur in RS X in the development of electronic-based nursing documentation are the factors of leadership, factors of means and factors of follow-up development of electronic nursing documentation. Method: In solving this problem, it is recommended to use Lewin's theory of change which consists of three phases: unfreezing, moving, and refreezing. Result: Stages of unfreezing: conducting evidence-based and literature review studies on the importance of electronic documentation, and brainstorming with the nurse actors change Phase Moving implementing the stages of implementation of electronic documentation development using the principles of 5 management functions namely planning, organizing, staffing, leading and controlling. Refreezing stages: provide supervisors, make Decree of Director and Standard of Operational Procedure about implementation of electronic-based nursing documentationin X Hospital Depok. Conclusion: In solving this problem, Lewin's theory of change consists of three pairs, namely unfreezing, moving, and refreezing.

Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews.

To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation. Systematic review of systematic reviews. We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches. Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis. Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important for high-quality nursing documentation. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation. There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.

The Implementation of Electronic based Nursing Care Documentation to EFETEC; A Literature Review

ABSTRACT
 In last two decades most of the tasks performed by nurses have not been directly related to patient care. Nurses spend more time on writing documentation or medical records of patients. Implementation of electronic medical record can reduce the time used for documentation or in other hand will increase the time for nurses to interact with patients then eventually can improve the quality of nursing care. Purpose of this literature review is to find out the implementation of electronic-based nursing care documentation (EHR) in improving the quality of nursing care in terms of EFETEC aspects. Method used by author is a literature review. Database used is Science Direct, PROQUEST, Scopus, Ebscho and Scholar Article with the keywords; electronic health record, EHR, Documentation in nursing, Quality of nursing care. Implementation of electronic nursing care documentation can improve the service quality. Improvement of the quality of service is reviewed with EFETEC which consists of efficient, focus for patient, effective, time discipline, equality, confidentiality. In the era of health workers 4.0 the utilization of electronic nursing care documentation requires continuous development in order to improve the quality of service for patients.
 KEYWORDS: electronic health record, nursing care documentation, quality of nursing care

Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study

Background: Completeness of documentation as a legal aspect and proof a nursing activity. Nothing documentation means nothing activity.Objective: The Purpose of research to identify the legal aspect and completeness of nursing documentation after applying electronic nursing documentation.
 Methods: Report study approach and using pre and post-test with the control group. Thirty Four documentation collected using consecutive sampling on one-week observation before and after using electronic nursing information. The research compared the legal aspect and completeness of data conducted before and after the implementation of the new system.Results: The study showed improvement of the legal aspects increased by 50% (4,40 to 8,00) and completeness documentation by 10.39% (43,00 to 49,00) after used of a system. 
 Conclusion: Nursing Electronic Documentation improved legal aspect, completeness nursing and enhance the quality of nursing care.
 Recommendation: Electronic nursing documentation can be done to support and increase the quality of nursing.

Metode Pendokumentasian Elektronik dalam Meningkatkan Kualitas Pelayanan Keperawatan

Nursing documentation is one of the most important functions for nurses in providing nursing care. The nursing process in the modern era is now a demand from various aspects for nurses. The current development is that nurses must carry out nursing processes based on nursing care standards. The use of electronic nursing documentation can always evolve in line with technological developments, this can increase client life expectancy and reduce errors in intervening with clients. This IT-based documentation system will help in meeting documentation standards, can improve the quality of documentation, facilitate decision making and provide information that is easy to access, can minimize the potential for loss or damage to development records, improve information exchange and coordination between nurses or other health teams, documentation can be easily audited, help improve the accuracy of client data, can access the progress of client health development and reduce maintenance costs so that it can improve the quality of care services.

Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review.

To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings. Electronic documentation has been recommended to improve quality care and patient safety. With the gradual move from paper-based to electronic nursing documentation internationally, there is a need to identify interventions that can effectively improve quality care and patient safety. We conducted a systematic review on the effectiveness of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings. Six articles reporting on six individual studies met all eligibility criteria. They were uncontrolled pre/post intervention studies reporting positive impacts on at least one or more outcomes. Most outcomes related to documentation practice and documentation of content. Some evidence from our review indicates that implementing electronic nursing documentation in acute hospital settings is time saving, reduces rates of documentation errors, falls and infections. A planned approach from management over time to allow nurses adapt to new electronic systems of documentation would seem a good investment in terms of efficiency of work time, possibly resulting in more time for clinical care.

Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation at a hospital in Indonesia

ABSTRACTElectronic health records are expected to improve the quality of care provided to hospitalized patients. Electronic documentation implementation is a course of action that requires much time and attention. The study aimed to explore and describe the usability and satisfaction of using electronic documentation. Quantitative and descriptive qualitative research methods were done through focus group interviews involving eight nurses and a questionnaire survey to 219 nurses. Satisfaction before and after the implementation of the system was compared using thematic analysis and paired t-test. The system was developed with NANDA, NIC and NOC language and named as "SIMPRO". The results yielded themes on perception about usability, positive and negative responses, barriers to and expectations for successful implementation. SIMPRO was found to increase the nurse satisfaction and usability (p = 0.001). Training on the motives for change might strengthen the nurse's motivation and facilitate the transition to a new system. The study findings implied that electronic nursing documentation was an effective way to improve nursing documentation. In addition, support from the leader and organization might affect the effectiveness of the system implementation

Patient Accessible Electronic Health Records: Impacts on Nursing Documentation Practices at a University Hospital.

In a Norwegian health region, patients have online access to their own electronic health record and they can also read the nursing documentation. This paper presents a qualitative study made at a university hospital to investigate how patient accessible electronic health records impact on nursing documentation practices. Semi-structured interviews were made with 12 informants from 5 cardiology departments at one hospital regarding how they used electronic nursing documentation in their daily practice and how they experienced patient accessible nursing documentation. The nurses emphasized that they focused on a clear and well-written nursing documentation, but in some situations, they were hesitant to write sensitive information. The study concluded that the implementation of patients' reading access to the electronic health record had limited impact on the nursing documentation and the daily practice at the departments, but the nursing handover had an even more important function for oral exchange of information.

Nursing Care and Documentation Assistant with an Electronic Nursing Management System in Neonatal Intensive Care Unit

Background: All nursing cares require decision-making, and the ability to make the best decisions impact upon the quality of nursing care. Moreover, authenticity and accuracy of the best cares may be questioned if not recorded and reported properly and in a standard manner. We aimed to design and implement an electronic nursing managementsystem and then evaluate satisfaction of nurses with the designed electronic system.Methods: This technical action research was conducted in four phases of a) designing an electronic nursing process decision support system, b) designing an electronic nursing care documentation system, c) integrating these two systems and developing an electronic nursing information management system, and d) implementing the system and system satisfaction evaluation using quantitative methods (satisfaction questionnaire).Results: The results of this project led to design and development of an electronic nursing information management system for neonatal intensive care units, which enables nurses to carry out standard care and documentation with high level of nursing satisfaction.Conclusion: In order for an electronic system to support nurses in their care process, it must be accepted by nurses. If nurses are satisfied with the performance and nature of this system, they are much less likely to develop workaround solutions and much more likely to spend their efforts focusing on the professional aspects of nursing care.

Comparison Analysis between Integrated Nursing Care Service and Non Integrated Nursing Care Service through Electronic Nursing Documentation

Objectives The purpose of this study is to identify the differences between the integrated nursing care service and non integrated nursing care service through electronic nursing documentation. Methods We retrospectively reviewed the electronic nursing documentation of 102 patients who were admitted to G general hospital for analyzing the frequency of nursing statements between the month of January 2016 and the month of January 2017 using random sampling. The data were analyzed using percentage, mean, standard deviation, chi-square test and independent t-test with the SPSS Win 23.0 Program. Results The frequency of use for the nursing statements was investigated: there was a significant difference in nursing record on pain assessment (p<0.001), nurse rounding, fall prevention (p=0.001), rounding for voiding, oral medication counseling, skin assessment, oral care, cold pack apply, bath, shampoo, face wash and teeth brushing, meal assistance, hot pack apply and tube feeding (p<0.001) between the integrated nursing care service and non integrated nursing care service. There was no significant difference in the frequency of nursing diagnosis. Conclusions Results confirm that the nurse’s job had changed in the integrated nursing care service for example the direct patient care related in daily living assistance. Based on these results, the additional efforts to increase the records of patient education, counseling and emotional assessment are needed in order to improving the effective integrated nursing care service through job analysis. Key words: Nurse, Integrated nursing care service, Electronic nursing documentation

Exploring nurses’ reactions to electronic nursing documentation at the point of care

PurposeThe purpose of this paper is to investigate nurses’ attitudes, perceptions, and reactions to a new point-of-care information system for documenting nursing care.Design/methodology/approachA design science research methodology (DSRM) was used to examine the feasibility and usability of a novel nursing informatics solution in the context of acute hospital care. Data were collected using focus groups and non-participant observations. Analyses were guided by the theoretical lens of actor-network theory (ANT).FindingsThe findings unpack an understanding of the potential value of a new technology, rather than a binary understanding of positive or negative value. Using the ANT lens, the study reveals the dynamics of the nurse-technology relationships and consequent disruptions throughout the translation process. The findings highlight the central role of negotiation in the socio-technical construction of the hybrid actor-network during the implementation of new technology in acute hospital contexts.Research limitations/implicationsFurther studies are needed to investigate the dynamics and complexity of the translation process that occurs during technology adoption, reactions of the involved actors to the emerging network and impacts on their role and work process.Practical implicationsEngaging nurses early during development and testing; aligning the new system’s functionality and interface with nurses’ interests and work practices; and supporting changes to clinical work process to enable an effective heterogeneous actor-network to emerge and become stable.Originality/valueThis study presents a novel use of ANT in a DSRM to understand an enterprise-wide system involving nurses and real clinical settings. The emerged actor-network provides insights into the translation process when nurses adapt to using new technology in their work.

Developing a prenatal nursing care International Classification for Nursing Practice catalogue.

This study aimed to develop a prenatal nursing care catalogue of International Classification for Nursing Practice. As a programme of the International Council of Nurses, International Classification for Nursing Practice aims to support standardized electronic nursing documentation and facilitate collection of comparable nursing data across settings. This initiative enables the study of relationships among nursing diagnoses, nursing interventions and nursing outcomes for best practice, healthcare management decisions, and policy development. The catalogues are usually focused on target populations. Pregnant women are the nursing population addressed in this project. According to the guidelines for catalogue development, three research steps have been adopted: (a) identifying relevant nursing diagnoses, interventions and outcomes; (b) developing a conceptual framework for the catalogue; (c) expert's validation. This project established a prenatal nursing care catalogue with 228 terms in total, including 69 nursing diagnosis, 92 nursing interventions and 67 nursing outcomes, among them, 57 nursing terms were newly developed. All terms in the catalogue were organized by a framework with two main categories, i.e. Expected Changes of Pregnancy and Pregnancy at Risk. Each category had four domains, representing the physical, psychological, behavioral and environmental perspectives of nursing practice. This catalogue can ease the documentation workload among prenatal care nurses, and facilitate storage and retrieval of standardized data for many purposes, such as quality improvement, administration decision-support and researches. The documentations of prenatal care provided data that can be more fluently communicated, compared and evaluated across various healthcare providers and clinic settings.

Support of the nursing process through electronic nursing documentation systems (UEPD) – Initial validation of an instrument

Electronic nursing documentation systems, with standardized nursing terminology, are IT-based systems for recording the nursing processes. These systems have the potential to improve the documentation of the nursing process and to support nurses in care delivery. This article describes the development and initial validation of an instrument (known by its German acronym UEPD) to measure the subjectively-perceived benefits of an electronic nursing documentation system in care delivery. The validity of the UEPD was examined by means of an evaluation study carried out in an acute care hospital (n = 94 nurses) in German-speaking Switzerland. Construct validity was analyzed by principal components analysis. Initial references of validity of the UEPD could be verified. The analysis showed a stable four factor model (FS = 0.89) scoring in 25 items. All factors loaded ≥ 0.50 and the scales demonstrated high internal consistency (Cronbach's α = 0.73 – 0.90). Principal component analysis revealed four dimensions of support: establishing nursing diagnosis and goals; recording a case history/an assessment and documenting the nursing process; implementation and evaluation as well as information exchange. Further testing with larger control samples and with different electronic documentation systems are needed. Another potential direction would be to employ the UEPD in a comparison of various electronic documentation systems.