Evaluation of vocal-electronic nursing documentation: A comparison study in Iran. (3rd July 2017)

• Record Type: Journal Article
• Authors: Mohammadi Firouzeh, Mona; Jafarjalal, Ezzat; Emamzadeh Ghasemi, Hormat Sadat; Bahrani, Naser; Sardashti, Sara
• Is Part Of: Informatics for health & social care. Volume 42:Number 3(2017)
• Page Start: 250
• Page End: 260
• Publication Date: 2017-07-03
• Subjects: Electronic health records -- healthcare documentation -- nursing -- quality assurance; Medicine -- Information services -- Periodicals; Medical informatics -- Periodicals; Medicine -- Data processing -- Periodicals; 025.0661
• DOI: 10.1080/17538157.2016.1178119
• Languages: English
• ISSNs: 1753-8157

Abstract

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.