Effect of electronic report writing on the quality of nursing report recording

Abstract

Background and AimRecording performed nursery actions is one of the main chores of nurses. The findings have shown that recorded reports are not qualitatively valid. Since electronic reports can be regarded as a base to write reports, this study aims at determining the effect of utilizing electronic nursing reports on the quality of the records.MethodsThis quasi-experimental study was conducted with the aim of applying an electronic system of nursing recording in the heart department of Shahid Rahimi Medical Center, Lorestan University of Medical Science. The samples were nursing reports on the hospitalized patients in the heart department, the basis of complete enumeration (census) during the fall of 2014. The subjects were sixteen employed nurses. To do the study, the software of nursing records was set based on the Clinical Care Classification system (CCC). The research’s tool was the checklist of the Standards of Nursing Documentation.ResultsThe findings indicated that before and after the intervention, the amount of reports’ adaption with the written standards, respectively, was (21.8%) and (71.3%), and the most complete recording was medicine status (58%) and (100%). The worst complete recording before the intervention, acute changes was (99.1%) and nursing processes was (78%) and after, the medicine status, intake and output status and patient’s education (100%); while the nursing report structure was regarded in all cases (100%). The results showed that there is a significant difference in the quality of reporting before and after using CCC (p<0.001).ConclusionsSince the necessary parameters for recording a standard report do exist in electronic reporting (CCC), from one point, nurses are reminded to record the necessary parts and from the other point, the system does not allow the user to shut it down unless the necessary parameters are recorded. For this reason, the quality of recorded reports with electronic reporting improves.

Development and evaluation of an electronic nursing documentation system

“…Our software indicated that with the advancement of EMR in nursing practice, many paper-based reporting problems such as; wasted time, disruption in design and clinical care the patients, medical errors, endangering patients’ safety, fading and illegibility of manual documentation, legal problems, and, other similar issues. Are resolved [ 8 , 9 ]. The electronic system developed in this study allows the nurses to fill out the pre-designed standard platform at the patient’s bedside, eliminating the need to write on paper and transfer the information to the system.…”

“…Currently, the clinical nursing reporting in most hospitals in Iran is paper-based which may be similar to writing a story with a varied and inconsistent format. In most cases, there is no legislative defense for the nursing staff because of the gradual fading and illegibility of manual records [8,9]. Writing a nursing report is a routine event that that should be performed several times during a nurse's daily work, therefore, nurses spend about 37% of their entire working time writing reports [10][11][12].…”

Nursing informatics skills relevance and competence for final year nursing students

“…However, nursing informatics incompetence of nurses can result in less than optimal patient care (Jouparinejad et al 2020), which can result in suboptimal healthcare outcomes, such as decreased patient safety and errors in clinical practice (Konttila et al 2019;Rajalahti, Heinonen & Saranto 2014). Similarly, nurses' attitude towards the use and acceptance of technology in nursing practice may affect their competency in nursing informatics and their adoption of healthcare technology (Heidarizadeh et al 2017;Kaminski 2010;Mutula 2015).…”

The effect of peer teaching on the quality of report writing based on the nursing process

“…[ 2 ] Therefore, nurses must convey information about the patient accurately, in a timely and effective way. [ 3 ] Despite the importance of nursing reporting, researches indicate the unfavorable status of care registration and the lack of a proper framework for recording nursing care,[ 4 ] and the low quality of nursing reporting and documentation. [ 5 6 ] Many nurses have not been successful in meeting the existing documentation standards or guidelines.…”