Evaluation of vocal-electronic nursing documentation: A comparison study in Iran

Firouzeh, Mona Mohammadi; Jafarjalal, Ezzat; Ghasemi, Hormat Sadat Emamzadeh; Bahrani, N; Sardashti, Sara

doi:10.1080/17538157.2016.1178119

Cited by 7 publications

(4 citation statements)

References 40 publications

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“…Beberapa tahun belakangan ini pengembangan teknologi dalam pelayanan keperawatan banyak bermunculan, salah satunya adalah dalam pengembangan dokumentasi keperawatan berbasis elektronik. Kualitas dokumentasi keperawatan dalam sistem elektronik secara signifikan lebih baik daripada sistem dokumentasi berbasis kertas (Mohammadi Firouzeh, Jafarjalal, Emamzadeh Ghasemi, Bahrani, & Sardashti, 2017).…”

Section: Pendahuluanunclassified

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Perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan berbasis kertas: Study literature

Suganda

Hariyati

2020

J.HolHealth

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Paper‐based versus electronic‐based of health records in quality of nursing documentation: A literature review study.Background: Many technological developments in nursing services have emerged, one of them is electronic-based nursing documentation. The electronic nursing documentation has a good impact which increases the quality of service. But the readiness is still questionable.Purpose: Describing the quality comparison of electronic-based nursing documentation and paper-based nursing documentation.Method: This study uses a PRISMA literature review. Through the remote-lib.ui.ac.id database that is connected to various scientific publication pages such as, Scopus, Ebsco, PROQUEST Scholar-Articles with several key words such as electronic nursing documentation, nursing paper documentation, management information systems.Results: Electronic-based documentation has a higher level of quality documentation than paper-based documentation in terms of efficiency, effectiveness, patient focus and timeliness.Conclusion: Electronic-based documentation offers the optimization of nursing care, effective and efficient documentation, integrated nursing care and cost-effective through (paperless). Strong support from hospital institutions, organizations and government at the beginning of the nurse adaptation system and process is a challenge so that the application of electronic nursing documentation is realized properly.Keywords: Paper‐based; Electronic‐based; Health records; Quality; Nursing documentation.Pendahuluan: Pengembangan teknologi dalam pelayanan keperawatan banyak bermunculan, salah satunya dokumentasi keperawatan berbasis elektronik. Dokumentasi keperawatan elektronik memberikan dampak baik yang luarannya meningkatkan kualitas pelayanan. Namun kesiapan masih dipertanyakan.Tujuan: Menggambarkan perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan dokumentasi keperawatan berbasis kertas.Metode: Penelitian ini menggunakan tinjauan pustaka PRISMA. Melalui Database remote-lib.ui.ac.id yang terhubung dengan berbagai macam laman publikasi ilmiah seperti, Scopus, Ebsco, PROQUEST, Scholar-Artikel dengan beberapa kata kunci seperti dokumentasi keperawatan elektronik, dokumentasi keperawatan kertas, sistem informasi manajemen.Hasil: Dokumentasi berbasis elektronik memiliki tingkat kualitas dokumentasi lebih dibandingkan dokumentasi berbasis kertas secara efesiensi, efektifitas, fokus pada pasien maupun ketepatan waktu.Simpulan: Dokumentasi berbasis elektronik menawarkan keoptimalan melakukan asuhan keperawatan, dokumentasi efektif dan efesien, asuhan keperawatan terintegrasi serta cost-effective melalui (paperless). Dukungan kuat dari institusi rumah sakit, organisasi maupun pemerintah dalam permulaan sistem dan proses adaptasi perawat menjadi tantangan, agar penerapan dokumentasi keperawatan elektronik terealisasi dengan baik.

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Section: Pendahuluanunclassified

“…Kualitas dokumentasi keperawatan dalam sistem elektronik secara signifikan lebih baik daripada sistem dokumentasi berbasis kertas (Mohammadi Firouzeh et al, 2017).…”

Section: Pembahasanunclassified

Perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan berbasis kertas: Study literature

Suganda

Hariyati

2020

J.HolHealth

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“…Hasil penelitian ini menemukan perbedaan yang signifikan dalam kualitas dokumentasi keperawatan di dua rumah sakit, baik sebelum dan sesudah penerapan sistem catatan kesehatan elektronik (p <0,001). Kualitas dokumentasi keperawatan elektronik secara signifikan lebih baik daripada sistem dokumentasi berbasis kertas (Mohammadi Firouzeh, Jafarjalal, Emamzadeh Ghasemi, Bahrani, & Sardashti, 2017).…”

Section: Hasilunclassified

Dampak Penerapan Sistem Pencatatan Keperawatan Elektronik: Literatur Review

Dewi

2019

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Catatan keperawatan adalah suatu laporan baik komunikasi secara lisan, tertulis maupun melalui komputer untuk menyampaikan informasi kepada orang lain. Perkembangan teknologi informasi digital yang sangat cepat dalam dunia kesehatan, membawa dampak pada kemajuan yang cukup berarti dalam bidang keperawatan. Catatan keperawatan dari yang sebelumnya manual, bergeser menjadi komputerisasi. Tujuan penulisan ini untuk melihat dampak penerapan sistem pencatatan keperawatan elektronik. Metode yang digunakan adalah literature review, pencarian menggunakan beberapa database elektronik, yakni Google Scholar, ProQuest, SpringerLink, CINAHL dan ScienceDirect dengan menggunakan kata kunci the impact of electronic nursing recording systems, information technology. Hasil telaah ditemukan bahwa penerapan sistem pencatatan keperawatan elektronik ini memberikan dampak terhadap peningkatan kualitas asuhan keperawatan, efisiensi dan keamanan data pasien. Kesimpulannya diperlukan dukungan manajer dan keterlibatan perawat dalam pengembangan desain sistem, agar perawat terus menggunakannya untuk meningkatkan mutu dan keselamatan pasien.

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“…Despite the criticality of documentation, however, studies conducted in Iran showed that the quality of medical records in the country’s hospitals is unsatisfactory [ 8 ] [ 11 ]. Research that compared world standards with those of Iran revealed that nurses in other countries exhibit more desirable quality regarding adhering to documentation principles and standards [ 12 ].…”

Section: Introductionmentioning

confidence: 99%

Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran

Vafaei

Manzari

Heydari

et al. 2018

Open Access Maced J Med Sci

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BACKGROUND:Standardization of documentation has enabled the use of medical records as a primary tool for evaluating health care functions and obtaining appropriate credit points for medical centres. However, previous studies have shown that the quality of medical records in emergency departments is unsatisfactory.AIM:The aim of this study was improving the nursing care documentation in an emergency department, in Iran.MATERIAL AND METHODS:This collaborative action research study was carried out in two phases to improve nursing care documentation in cooperation with individuals involved in the process, from February 2015 to December 2017 in an affiliated academic hospital in Iran. The first phase featured virtual training, an educational workshop, and improvements to the hospital information system. The second phase involved the recruitment of human resources, the implementation of continuous codified training, the establishment of an appropriate reward and penalty system, and the review of patient education forms.RESULTS:The interventions improved nursing documentation quality score of 73.20%, which was the highest accreditation ranking provided by Iran’s Ministry of Health and Medical Education in 2017. In other words, this study caused a 32% improvement in the quality of nursing care documentation in the hospital.CONCLUSION:The appropriate practices for improving nursing care documentation are employee participation, managerial accountability, nurses’ adherence to documentation standards, improved leadership style, and continuous monitoring and control.

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Evaluation of vocal-electronic nursing documentation: A comparison study in Iran

Abstract: Vocal-electronic systems help to improve quality of nursing documentation, suggesting this aspect may be essential to implementing a successful system in local settings.

Cited by 7 publications

References 40 publications

Perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan berbasis kertas: Study literature

Perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan berbasis kertas: Study literature

Dampak Penerapan Sistem Pencatatan Keperawatan Elektronik: Literatur Review

Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran

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