Quality of nursing documentation: Paper‐based health records versus electronic‐based health records

@article{AkhuZaheya2018QualityON,
  title={Quality of nursing documentation: Paper‐based health records versus electronic‐based health records},
  author={Laila M. Akhu-Zaheya and Rowaida Al-Maaitah and Salam Bany Hani},
  journal={Journal of Clinical Nursing},
  year={2018},
  volume={27},
  pages={e578–e589}
}
AIMS AND OBJECTIVES To assess and compare the quality of paper-based and electronic-based health records. The comparison examined three criteria: content, documentation process and structure. BACKGROUND Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organised within the system known as the electronic health records. Nursing documentation must be completed at the highest standards, to ensure the safety and quality of… 

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References

SHOWING 1-10 OF 42 REFERENCES

Development of an audit instrument for nursing care plans in the patient record

The Cat-ch-Ing instrument has proved to be a valid and reliable audit instrument for nursing records when the VIPS model is used as the basis of the documentation.

Nurses' perceptions of an electronic patient record from a patient safety perspective: a qualitative study.

Efforts should be made to include the views of nurses when designing an electronic patient record to ensure it suits the needs of nursing practice and supports patient safety.

Nursing documentation of inpatient care in eastern Ghana.

The standard of nursing care documentation in Ghana is not on a par with that in developed countries, partly owing to a lack of guidelines, as well as a persistent shortage of nurses and the limited use of Nursing care records.

Quality of documentation of electronic medical information systems at primary health care units in Alexandria, Egypt.

  • M. NoureldinR. MosallamS. Z. Hassan
  • Medicine
    Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al-sihhiyah li-sharq al-mutawassit
  • 2014
Assessment of quality of documentation in the electronic medical records at primary health care units in Alexandria, Egypt and physician's feedback on barriers and facilitators to the system found high workload and system complexity were the most frequently mentioned barriers to implementation of the e-records system.

Nursing documentation audit--the effect of a VIPS implementation programme in Denmark.

The structured implementation programme significantly improved nursing documentation, and the simultaneous training of the entire nursing staff shows promise.

Factors Affecting the Adoption of Electronic Health Records by Nurses

The use of Electronic Health Records and barriers in using it among nurses in private medium sized hospitals of Tamil Nadu, India are explored and the factors affecting nurses to adopt electronic health record are analyzed.

Nurses Readiness and Electronic Health Records

  • Mahdi Habibi-KoolaeeR. SafdariH. Bouraghi
  • Medicine
    Acta informatica medica : AIM : journal of the Society for Medical Informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH
  • 2015
It should be considered in the education, training and participation of nurses, it should be ensured the level of knowledge and attitude toward EHR and some related courses in Health Information Systems suggested including the curriculum of nursing.

Nursing documentation in patient records: experience of the use of the VIPS model.

The findings showed that an intense process of change and development was occurring regarding nursing documentation, however, there were limitations in the use of the entire nursing process, especially in the specification of patient problems and the formulation of nursing diagnoses and nursing interventions.

Attitudes of health professionals towards electronic health records in primary health care settings: a questionnaire survey

Recommendations based on the findings include EHR technology refinements, improved clinical documentation using standardized terminologies, and health professional-informed EHR training.