Mona Mohammadi Firouzeh1,2, Ezzat Jafarjalal3, Hormat Sadat Emamzadeh Ghasemi4, Naser Bahrani5, Sara Sardashti1. 1. a Iranian Research Center for HIV/AIDS , Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences , Tehran , Iran. 2. b Department of Nursing Education and Management, Faculty of Nursing and Midwifery , Tehran University of Medical Sciences , Tehran , Iran. 3. c Department of Nursing Education and Management, School of Nursing and Midwifery , Iran University of Medical Sciences , Tehran , Iran. 4. d Faculty of Nursing and Midwifery , Tehran University of Medical Sciences , Tehran , Iran. 5. e Department of Mathematics-Statistics, Faculty of Sciences , Air University of Shahid Sattari , Tehran , Iran.
Abstract
AIM: Documentation is a critical element in the function of the nursing team, and cannot be separated from high-quality, patient-centered care. The aim of this study was to compare the quality of nursing documentation in electronic and paper-based systems. METHOD: A retrospective descriptive study was designed to compare the quality of nursing documentation in electronic health records (EHR) versus paper-based documentation systems before and after the application of the electronic system. RESULTS: Analysis of data found a significant difference in the quality of nursing documentation in the two hospitals both before and after the implementation of an EHR system (p < 0.001).Quality of nursing documentation in the electronic system was significantly better than that of paper-based documentation systems. CONCLUSION: Vocal-electronic systems help to improve quality of nursing documentation, suggesting this aspect may be essential to implementing a successful system in local settings.
AIM: Documentation is a critical element in the function of the nursing team, and cannot be separated from high-quality, patient-centered care. The aim of this study was to compare the quality of nursing documentation in electronic and paper-based systems. METHOD: A retrospective descriptive study was designed to compare the quality of nursing documentation in electronic health records (EHR) versus paper-based documentation systems before and after the application of the electronic system. RESULTS: Analysis of data found a significant difference in the quality of nursing documentation in the two hospitals both before and after the implementation of an EHR system (p < 0.001).Quality of nursing documentation in the electronic system was significantly better than that of paper-based documentation systems. CONCLUSION: Vocal-electronic systems help to improve quality of nursing documentation, suggesting this aspect may be essential to implementing a successful system in local settings.
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Keywords:
Electronic health records; healthcare documentation; nursing; quality assurance