Electronic nursing documentation interventions to promote or improve patient safety and/or quality care in an acute setting
Rapid review
Keywords:
care quality, electronic health records, electronic nursing documentation, health records, patient safetyAbstract
Research has demonstrated that the implementation of electronic nursing documentation interventions can enhance the precision and comprehensiveness of records, thereby providing a significant benefit. Electronic documentation systems help to reduce errors resulting from factors such as indecipherable handwriting, incomplete or absent documentation, and transcription errors. In May 2022, a comprehensive research was conducted in CINAHL, MEDLINE, Cochrane, and Web of Science to identify relevant literature for their study. The study focuses on the use of electronic health systems in nursing, specifically in the documentation of care plans, records, reports, and charts. Individuals utilizing any given database employ the tools at their disposal to conduct searches for document abstracts and titles. This rapid review comprised one cross-sectional, one randomised control trial, two quasi-experimental, one qualitative, and one cohort study. The US, Taiwan, and Jordan each held two tests. The six trials included a medical-surgical and telemetry hospital with 446 beds, an acute care hospital with 1037 beds, a medical-surgical unit, and an urgent care clinic. The results revealed that electronic nursing documentation has improved quality of nursing.
Downloads
References
Akinyemi, O. R., Sibiya, M. N., & Oladimeji, O. (2022). Communication model enhancement using electronic health record standard for tertiary hospital. South African Journal of Information Management, 24(1), 1472.
Alexander, G. L., & McMullen, T. (2023). Probing into federal policies and National Academies’ recommendations to adopt health information technology in all US nursing homes. Public Policy & Aging Report, 33(Supplement_1), S28-S34.
Avendano, J. P., Gallagher, D. O., Hawes, J. D., Boyle, J., Glasser, L., Aryee, J., ... & Aryee, J. N. (2022). Interfacing with the electronic health record (EHR): a comparative review of modes of documentation. Cureus, 14(6).
Bauer, J. C., John, E., Wood, C. L., Plass, D., & Richardson, D. (2020). Data entry automation improves cost, quality, performance, and job satisfaction in a hospital nursing unit. JONA: The Journal of Nursing Administration, 50(1), 34-39.
Bunce, A., Middendorf, M., Hoopes, M., Donovan, J., & Gold, R. (2022). Designing and implementing an electronic health record–embedded card study in primary care: methods and considerations. The Annals of Family Medicine, 20(4), 348-352.
Campbell, S. M., Roland, M. O., & Buetow, S. A. (2000). Defining quality of care. Social science & medicine, 51(11), 1611-1625. https://doi.org/10.1016/S0277-9536(00)00057-5
Cerchione, R., Centobelli, P., Riccio, E., Abbate, S., & Oropallo, E. (2023). Blockchain’s coming to hospital to digitalize healthcare services: Designing a distributed electronic health record ecosystem. Technovation, 120, 102480.
Cesare, N., & Were, L. P. (2022). A multi-step approach to managing missing data in time and patient variant electronic health records. BMC Research Notes, 15(1), 64.
Chen, Y., & Gong, Y. (2022). Teamwork and Patient Safety in Intensive Care Units: Challenges and Opportunities. Studies in health technology and informatics, 290, 469–473.
Dai, Z., He, Y., Zhang, X., Tian, Z., Zhu, G., Ren, Z., ... & Ji, T. (2023). Head and neck dermatofibrosarcoma protuberans: Survival analysis and immunohistochemical indicators. Oral Diseases.
Dickerson, A. (2023). Nurses’ Experiences Transitioning from Paper to Electronic Health Records: A Pilot Study (Doctoral dissertation, University of Mount Olive).
Eversberg, L., & Lambrecht, J. (2023). Evaluating Digital Work Instructions with Augmented Reality versus Paper-based Documents for Manual, Object-Specific Repair Tasks in a Case Study with Experienced Workers. arXiv preprint arXiv:2301.07570.
Gaertner, J., Zimmermann, F., & Simone 2nd, C. B. (2023). The value of patient reported outcomes in palliative radiotherapy: A discussion in light of current findings. Annals of Palliative Medicine, apm-23.
Guyer, A. C., Macy, E., White, A. A., Kuruvilla, M. E., Robison, R. G., Kumar, S., ... & Blumenthal, K. (2022). Allergy electronic health record documentation: a 2022 work group report of the AAAAI Adverse Reactions to Drugs, Biologicals, and Latex Committee. The Journal of Allergy and Clinical Immunology: In Practice, 10(11), 2854-2867.
Haas, S., Wohlgemuth, S., Echizen, I., Sonehara, N., & Müller, G. (2011). Aspects of privacy for electronic health records. International journal of medical informatics, 80(2), e26-e31. https://doi.org/10.1016/j.ijmedinf.2010.10.001
Hathaliya, J. J., Tanwar, S., Tyagi, S., & Kumar, N. (2019). Securing electronics healthcare records in healthcare 4.0: A biometric-based approach. Computers & Electrical Engineering, 76, 398-410.
Howes, C., & Smith, E. W. (1995). Relations among child care quality, teacher behavior, children's play activities, emotional security, and cognitive activity in child care. Early Childhood Research Quarterly, 10(4), 381-404. https://doi.org/10.1016/0885-2006(95)90013-6
Huang, C., Koppel, R., McGreevey, J. D., 3rd, Craven, C. K., & Schreiber, R. (2020). Transitions from One Electronic Health Record to Another: Challenges, Pitfalls, and Recommendations. Applied clinical informatics, 11(5), 742–754.
Jhaveri, P., Abdulahad, D., Fogel, B., Chuang, C., Lehman, E., Chawla, L., ... & Levi, B. (2022). Impact of scribe intervention on documentation in an outpatient pediatric primary care practice. Academic Pediatrics, 22(2), 289-295.
Joseph, M. M., Mahajan, P., Snow, S. K., Ku, B. C., Saidinejad, M., & COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE. (2022). Optimizing pediatric patient safety in the emergency care setting. Pediatrics, 150(5).
Kaelber, D. C., & Bates, D. W. (2007). Health information exchange and patient safety. Journal of biomedical informatics, 40(6), S40-S45. https://doi.org/10.1016/j.jbi.2007.08.011
Kruk, M. E., Lewis, T. P., Arsenault, C., Bhutta, Z. A., Irimu, G., Jeong, J., ... & Yousafzai, A. K. (2022). Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services. The Lancet.
Lee, M. N. (2022). Transitioning to Electronic Safe Sleep Documentation in the Neonatal Intensive Care Unit.
Lei, K. C., Loi, C. I., Cen, Z., Li, J., Liang, Z., Hu, H., ... & Ung, C. O. L. (2023). Adopting an electronic medication administration system in long-term care facilities: a key stakeholder interview study in Macao. Informatics for Health and Social Care, 1-15.
Lindsay, M. R., & Lytle, K. (2022). Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Applied Clinical Informatics, 13(03), 711-719.
Mandato, K., & Kulhanek, B. (2022). The Impact of Inadequate Training. In Healthcare Technology Training: An Evidence-based Guide for Improved Quality (pp. 11-17). Cham: Springer International Publishing.
Maphumulo, W. T., & Bhengu, B. R. (2019). Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review. Curationis, 42(1), 1-9.
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett‐Collins, G., Clancy, M., ... & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of nursing management, 27(3), 491-501.
Mebrahtu, T. F., Bloor, K., Ledward, A., Keenan, A. M., Andre, D., Randell, R., Skyrme, S., Yang, H., King, H., & Thompson, C. A. (2021). Effects of computerised clinical decision support systems (CDSS) on nursing and allied health professional performance and patient outcomes. The Cochrane Database of Systematic Reviews, 2021(3), CD014699.
Mehta, P. (2022). Clinical Decision Support System. In Health Informatics (pp. 95-102). Productivity Press.
Munyisia, E. N., Yu, P., & Hailey, D. (2011). Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff?. International journal of medical informatics, 80(11), 782-792. https://doi.org/10.1016/j.ijmedinf.2011.08.009
Munyisia, E. N., Yu, P., & Hailey, D. (2011). The changes in caregivers’ perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. International journal of medical informatics, 80(2), 116-126. https://doi.org/10.1016/j.ijmedinf.2010.10.011
Muthelo, L., Ntho, T. A., Mbombi, M. O., Phukubye, T. A., Bopape, M. A., & Mothiba, T. M. (2023). A Qualitative Study on Voices of South African Learner Nurses on Occupational Health and Safety during Clinical Learning: Pre-COVID-19 Pandemic. Nursing Reports, 13(1), 96-108.
Nannini, M., Biggeri, M., & Putoto, G. (2022). Health coverage and financial protection in Uganda: a political economy perspective. International journal of health policy and management, 11(9), 1894-1904.
Nordo, A. H., Levaux, H. P., Becnel, L. B., Galvez, J., Rao, P., Stem, K., Prakash, E., & Kush, R. D. (2019). Use of EHRs data for clinical research: Historical progress and current applications. Learning health systems, 3(1), e10076.
Park, Y., Bang, Y., & Kwon, J. (2022). Clinical decision support system and hospital readmission reduction: Evidence from US panel data. Decision Support Systems, 159, 113816.
Penfold, R. B., & Zhang, F. (2013). Use of interrupted time series analysis in evaluating health care quality improvements. Academic pediatrics, 13(6), S38-S44. https://doi.org/10.1016/j.acap.2013.08.002
Petersson, L., Larsson, I., Nygren, J. M., Nilsen, P., Neher, M., Reed, J. E., ... & Svedberg, P. (2022). Challenges to implementing artificial intelligence in healthcare: a qualitative interview study with healthcare leaders in Sweden. BMC Health Services Research, 22(1), 1-16.
Putra, I. K., Ratnawati, G. A. A., & Sutapa, G. N. (2021). General radiographic patient dose monitoring using conformity test data. International Research Journal of Engineering, IT & Scientific Research, 7(6), 219-224.
Pylypchuk, Y., & Johnson, C. (2022). New EHR certification requirements and their association with duplicate tests and images. Journal of the American Medical Informatics Association, 29(8), 1391-1399.
Pyron, L., & Carter-Templeton, H. (2019). Improved Patient Flow and Provider Efficiency After the Implementation of an Electronic Health Record. CIN: Computers, Informatics, Nursing, 37(10), 513-521.
Ratnawati, I. G. A. A., Trisnawati, N. L. P., & Sutapa, G. N. (2021). CT-Scan Patient Dose Monitoring on Thorax Examination in General Hospital Sanjiwani Gianyar. International Research Journal of Engineering, IT and Scientific Research, 7(6), 214-218.
Reisman M. (2017). EHRs: The Challenge of Making Electronic Data Usable and Interoperable. P & T : a peer-reviewed journal for formulary management, 42(9), 572–575.
Russo, E., Sittig, D. F., Murphy, D. R., & Singh, H. (2016, December). Challenges in patient safety improvement research in the era of electronic health records. In Healthcare (Vol. 4, No. 4, pp. 285-290). Elsevier. https://doi.org/10.1016/j.hjdsi.2016.06.005
Saraswasta, I. W. G., & Hariyati, R. T. S. (2021). A systematic review of the implementation of electronic nursing documentation toward patient safety. Enfermería Clínica, 31, S205-S209. https://doi.org/10.1016/j.enfcli.2020.12.023
Schenk, E., Schleyer, R., Jones, C. R., Fincham, S., Daratha, K. B., & Monsen, K. A. (2018). Impact of Adoption of a Comprehensive Electronic Health Record on Nursing Work and Caring Efficacy. Computers, informatics, nursing : CIN, 36(7), 331–339.
Subbe, C. P., & Bramley, R. (2022). Digital NEWS? How to amplify the benefits of NEWS in a digital healthcare system.
Tanwar, S., & Bhardwaj, M. S. (2022). The Impact of Information Technology on Patient Health and Safety. JOURNAL OF ALGEBRAIC STATISTICS, 13(2), 779-787.
Tubaishat, A. (2019). The effect of electronic health records on patient safety: A qualitative exploratory study. Informatics for Health and Social Care, 44(1), 79-91.
Vela, D., Vela‐Gaxha, Z., Rexhepi, M., Olloni, R., Hyseni, V., & Nallbani, R. (2022). Efficacy and safety of tocilizumab versus standard care/placebo in patients with COVID‐19; a systematic review and meta‐analysis of randomized clinical trials. British Journal of Clinical Pharmacology, 88(5), 1955-1963.
Vercell, A., Gasteiger, N., Yorke, J., & Dowding, D. (2022). Patient-facing cancer mobile apps that enable patient reported outcome data to be collected: A systematic review of content, functionality, quality, and ability to integrate with electronic health records. International Journal of Medical Informatics, 104931.
Wani, D., & Malhotra, M. (2018). Does the meaningful use of electronic health records improve patient outcomes?. Journal of Operations Management, 60, 1-18. https://doi.org/10.1016/j.jom.2018.06.003
Youn, S., Geismar, H. N., & Pinedo, M. (2022). Planning and scheduling in healthcare for better care coordination: Current understanding, trending topics, and future opportunities. Production and Operations Management, 31(12), 4407-4423.
Zikos, D., Diomidous, M., & Mpletsa, V. (2014). The effect of an electronic documentation system on the trauma patient’s length of stay in an emergency department. Journal of emergency nursing, 40(5), 469-475. https://doi.org/10.1016/j.jen.2013.10.008
Published
How to Cite
Issue
Section
Copyright (c) 2023 International journal of health sciences
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Articles published in the International Journal of Health Sciences (IJHS) are available under Creative Commons Attribution Non-Commercial No Derivatives Licence (CC BY-NC-ND 4.0). Authors retain copyright in their work and grant IJHS right of first publication under CC BY-NC-ND 4.0. Users have the right to read, download, copy, distribute, print, search, or link to the full texts of articles in this journal, and to use them for any other lawful purpose.
Articles published in IJHS can be copied, communicated and shared in their published form for non-commercial purposes provided full attribution is given to the author and the journal. Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in this journal.
This copyright notice applies to articles published in IJHS volumes 4 onwards. Please read about the copyright notices for previous volumes under Journal History.
