Electronic nursing documentation for patient safety, quality of nursing care, and documentation: a systematic review

Authors

  • Erna Dwi Wahyuni Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
  • Nursalam Nursalam Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
  • Yulis Setiya Dewi Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
  • Hidayat Arifin Department of Nursing, Universitas Airlangga, Surabaya, Indonesia
  • Lizy Sonia Benjamin Department of Medical-Surgical Nursing, King Khalid University, Abha, Saudi Arabia

DOI:

https://doi.org/10.47391/JPMA.9996

Keywords:

Documentation, Electronic health documentation, Nursing, Patient safety, Quality of healthcare

Abstract

Objective: To evaluate the impact of electronic nursing documentation on patient safety, quality of nursing care and documentation.

Method: The systematic review was conducted in December 2022, and comprised a comprehensive search on Scopus, ScienceDirect, ProQuest, PubMed, Cumulative Index to Nursing and Allied Health Literature, Sage Journals and Google Scholar databases for English-language human studies published between 2018 and 2022. The key words used in the search included "Nursing", "care", "documentation", "record", "electronic", "process" and "health services". The risk of bias was assessed using Strengthening the Reporting of Observational Studies in Epidemiology tool.

Results: Of the 469 items initially identified, 15(3.2%) were analysed in detail, indicating a positive influence of electronic nursing documentation on patient safety, care quality, and documentation. However, shortcomings were observed in the development of electronic nursing documentation for optimal effectiveness.

Conclusion: Electronic nursing documentation significantly enhanced patient safety, care quality and documentation. To facilitate its integration into clinical settings, a standardised and logically structured electronic nursing documentation system is essential.

Key Words: Documentation, Electronic health documentation, Nursing, Patient safety, Quality of healthcare.

Published

2024-08-23

How to Cite

Wahyuni, E. D., Nursalam, N., Dewi, Y. S., Arifin, H., & Benjamin, L. S. (2024). Electronic nursing documentation for patient safety, quality of nursing care, and documentation: a systematic review. Journal of the Pakistan Medical Association, 74(9), 1669–1677. https://doi.org/10.47391/JPMA.9996

Issue

Section

SYSTEMATIC REVIEWS

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