THE PROCESS OF DOCUMENTATION, INFORMATION

TECHNOLOGY ADOPTION, AND THE QUALITY OF

NURSING SERVICES
I.

Background
Nursing profession as one of individual health services has a very

important role. It is represented to support the client's care during the healing
period. There are several important processes in this profession, such as
documentation, information technology adoption, nursing process and quality. All
these steps determine the professionalism.
One step in the process of care is the documentation. It is fatal if there is
an error in documentary because it will have an impact in the treatment process.
IT technologys support becomes very relevant for the accuracy and effectiveness
of documentation, which ultimately deliver improved quality of health services. It
is known that there is a causal cycle between process documentation, IT adoption,
and the quality of nursing services.
Documentation is an important aspect of nursing practice. All the
information about the client's circumstances and needs of nursing should be based
on the fact that no misinterpretation occurs during the client in treatment (Jasun,
2006), documentation is also useful as care reimbursement guidelines, quality
assurance inspection of materials, and legal documents as evidence in a court of
law (Nurjannah, 2005).
The phenomenon of implementation of the documentation is influenced by
several factors, such as management factors, motivational factors, infrastructure
factors, and the time factor. It is represented by the results of the study Safriana,
Trisna (2008) that showed quite adequate results. The data showed that the
individual nurses gave good care in work environment to deliver improved quality
of nursing services.
However, it is still found that workload of nurses, quality of
documentation, and implementation factors of documentation that occurred in
some health institutions in Indonesia are showing a weakness and less than
optimal performance. The study by Cornelia,et all (2007) about the relationship

load nurses working with the quality of nursing care documentation at the patients
of Hospital Room Sylvanus Dr. Doris Palangkaraya, show that the workload
quality of documentation is less severe trend (0%), workload mild tendency
documentation quality is less (53.8%). It can be seen that the load heavy work or
light work load documentation showing the quality is less, meaning
documentation quality is still very far from adequate, the consequences of nursing
actions will not be accurate so that the value of nursing services declined.
These two results of research documentation processes that occur in
Indonesia seem much to be done to reform nursing services particularly in terms
of documentation. In addition, the role of IT technology should be applied in
order to maximize the phenomenon of workload and quality of documentation.
Information and communication technology has developed rapidly Indonesia.
Therefore, it must be absorbed by the nurses in order to improve individual
quality, quality of documentation, and quality of care (Sitorus, 2004).
In this case, there is such effort to link the documentation, the absorption
of IT or Information and Technology adoption and the quality of nursing services
to demonstrate the unity of interests among others. It is expected that the nurse
has the professionalism by improving these factors. If the nurse is able to apply
the great documentation process, to implement the absorption of IT and to realize
the quality of nursing services, so it will be found the significant improvement. It
can be said that she can build up the quality of service to the patients very well
(Indonesia Nutrition Network, 2002).

II. Literature Review

II.1 Nursing Process Documentation
Potter (2005) defines that nursing documentation is a record that contains
all the information that are needed to determine the nursing diagnoses, nursing
plan, evaluating and implementing actions which are systematically compiled,
valid and morally justifiable and legal. Nevertheless, many nurses thought that
documentation is to carry out the work load documentation. Because of that, the
relationship of the nurse workload documentation quality of nursing care is
important to know in order to improve the quality of nursing care documentation.
The nursing process has 5 (five) steps, such as: assessing, analyzing, planning,
implementing, and evaluating.
The process that has been documented in the manual, technological
developments are still at the level of recording, writing, and storing, of each
phases and separate. The development of analog technology to digital technology
makes documentation process to change anyway, so the adaptation user
technologies such as nurses are required adapt to technological developments
digitizing.
Documentation is an essential part of the treatment process; one goal is a
good improvement of care and professionalism of nurse. A clients electronic
health record is a collection of the personal health information of a single
individual, entered or accepted by health care providers, and stored electronically,
under strict security. As with traditional or paper-based systems, documentation in
electronic health records must be comprehensive, accurate, timely, and clearly
identify who provided what care (Bungard. B, 2008).
To achieve these goals, it is needed to support technology tools for
maximizing results. Information and communication technologies are evolving at
this time. IT has been widely used to support the documentation process,
particularly on the process retrieval of data, where data exist has a different
character each other. There are three typology methods of documentation, such as
the focus charting, soap charting, and narrative chat.
Nurses as perpetrators of the current documentation already have an
understanding, attitudes, and preferences are significantly associated with the use
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of technology in the documentation process. Based on the results of research

conducted by Saranto Kaija, et al, (2009) there are four points shows the results of
a positive evaluation on the application of technology in the process of
documentation, an increase in quality and process care, increased knowledge and
computer technology.
The documentation of nursing care, using an electronic health record
demonstrates the impact of nursing care on patient care and validates the
significance of nursing practice. The use of structured nursing terminology in
electronic patient record systems will extend the scope of documentation research
from assessing the quality of documentation to measuring patient outcomes.
Developing information technology innovation very well is received by an
increase in work of nurse index. Documentation by adopting the technology will
impact on the intensity of care for patients and improve practice of nursing.
Standardization of terminology in electronic record systems via the IT system will
expand the quality of care outcome study documentation. Apparent relationship
documentation and the use of IT technology is a part that could encourage
increased professionalism of nurses themselves. When nurses have the ability to
adopt IT in good and correct method, it will give the impact of nursing services,
which in turn generate benefits in organizations health institutions.
II. 2 IT Adoption in the Realm of Nursing

The development of information and communication technology is very

rapid. As the example, search engine machine like "Google" and "Yahoo" can be
maximized to download information or literature in order to improve knowledge
and health services. Adoption of IT for the system clinical information is also a
generation of information technology in health care home ill. Research conducted
by Ursula Hbner, et al, shows the rate of adoption use of information technology
in clinical information systems at a hospital in Germany and Austria. Even the
concept of the future of creation of 'DIGITAL HOSPITAL', is a hospital based on
digital technology.
The ability of the adoption of IT technology is very dependent upon the
interaction of tasks, technology, and individual nurses. When the adoption process

fails especially at the time of the application documentation service to be not

optimal, the effectiveness and efficiency of care services falls its quality. There
was a problem between tasks, individuals, and the technology adoption process.
Case in the dermatology and cases in the Pediatric show different ability of
adoption. It is found more problems in Pediatric that occurred.
Adoption of IT by nurses showed positive values that should be
developed, information technology "world wide web" is the source of information
that the validity accepted by the researchers. International Journal in the realm of
medical and nursing is very widely spread in the vast network of the earth's
surface, this is a secondary resource who have academic value is up to date. It
takes time to think critically to understand the information from the website in
order to provide justification in the nursing process. The process of fitting
individual nurses in adopting IT technology affects the validity documentation in
the nursing process.
The results of research in the realm of current treatments widely
publicized through the journals, information technology through the internet, can
be downloaded in order to expand understanding according to the degree of
difficulty was encountered during the process of care for patients. The material
was drawn from three databases: CINAHL, PubMed and Cochrane using the
keywords nursing documentation, nursing care plan, nursing record system,
evaluation and assessment. The search was confined to relevant electronically
retrievable studies published in the English language from 2000 to 2007.
A descriptive study of 100 nursing personnel at a large Magnet hospital in
Southwest Florida was conducted to assess their needs, preferences, and
perceptions associated with Electronic Health Record (EHR) documentation
methods. Nurses attitudes about the use of EHRs and their perceived effects on
patient care were assessed.
Developed countries have implemented more advanced IT, whether it has
been also applying IT technology devices, especially on the activities of the
documentation process nursing so that the results of the next stage more leverage.
From the description above can be understood that the IT technology
provides improved quality in nursing services through the documentation process

based on IT technology. Ability adopted by nurses to be the key to the success of

the quality of nursing services. Next question is how abilities and skills can be
measured if it is no charge of IT in the learning process or in the process of
education? In developed countries there is a kind of consensus shared between
researchers and health professionals that IT has significant potential for
improvisation to improve quality of care, prevent errors medic, increase efficiency
care, and reduce maintenance costs.
One study on the performance impact of IT usage or nurse work index
showed the significant results, that the Nursing Information Technology at the
level of unit and home ill show median average 3:08 and 3:02. This indication can
be mentioned that the unit smaller nearly equal impact on a broader level in the
home ill. The significance of this should be observed that the role of IT will
improve the quality of care the macro-level hospitals. In an agency that serves
more than 28.000 patients each day in over a dozen different programs, it is
necessary to monitor trends in healthcare quality and ensure that patients receive
the most appropriate level of care and services. Recent HIT applications have
assisted VNSNY (The Visiting Nurse Service of New York) in meeting this
objective.
The use of VNSNY that adopts information technology is able to monitor
the trend of quality of care and ensure that patients get adequate treatment for
patients 28.000 thousand. This shows the effectiveness target number of patients
who underwent a scheduled basis. Therefore, no wonder that the role of use
results showed that the optimal technology for a wide range of activities within.
Technological capabilities will ease the burden of direct human labor, so the nurse
takes a more important role, especially in direct contact with the nurses without
burdened with the documentation process. Documentation process can be
completed by the device information and communication technology.
The era of globalization and information age has entered into all corners of
the world, including developing countries such as Indonesia. This has made new
demands on all sectors in our country, is no exception in the health care sector.
The era of globalization and the information seemed to have created a new
standard to be met by all players in this sector. This has made the world of nursing

in Indonesia are challenged to continuously improve the quality of nursing care

based on information technology.
One of the health information technology systems and is developing an
electronic health data storage system or in the English language known as the
Electronic Health Record. Electronic health data storage system contains about
patient demographics, progress notes, medical problems, drugs used, vital signs,
past medical history, laboratory data and radiology reports.
Electronic health data storage systems is to automate and streamline the
workflow of the clinician, effective and efficient. The storage system of electronic
health data entered in clumps Health Information Technology (HIT), has
contributed heavily in improving safety, effectiveness and efficiency in health
care. Almost 80% of medical errors can be avoided by storing electronic data
(Simpson, 2003).
Electronic Health Record has the ability to produce a complete record of
patient encounters, as well as supporting other care-related activities directly or
indirectly. Since the Electronic Health Record is an electronic device requires the
user is required to operate a proficient in computer and software.
The storage system of electronic patient health data has been abroad, but
their use is growing rapidly in some countries is still low, including in Indonesia.
Various kinds of constraints that often arises is considered the quantity and quality
of human resources to the quantity and quality of the computer as a recording
device. Yet when seen from the urgency and importance, then the electronic health
record systems are very influential on the quality of nursing care in hospitals or in
other health facilities.
II.3 Quality of Nursing Service
The quality of nursing services in hospitals and other health facilities are
very dependent on the speed, convenience, and accuracy in performing nursing
actions. It also means that nursing services depend on the efficiency and
effectiveness of the overall structural system is in a hospital or health facility.
Deese & Stein (2004) reported 50% reduction in the time of discovery in terms of
data when compared with the conventional way. Electronic data storage system
can reduce time of 1.5 hours per nurse within 12 hours. The store of electronic

data to reduce deaths and injury in patients is because the nurses have more time
with patients. It can be said that the use of electronic health records are up to now
still limited to large private hospitals and teaching hospitals, while in some area
hospitals are still not utilizing this technology though it will affect the quality and
quality of service.
According to HIMSS (Health Management Information Systems
Society's), which is an Electronic Health Record is the "electronic record length
containing patient health information generated by one or more meetings in the
setting of care delivery. This information includes patient demographics, progress
notes, medical problems, use of drugs, vital signs, past medical history,
immunization data, laboratory data and radiology reports. This Electronic Health
Record automates and streamlines the clinician workflow. Electronic Health
Record has the ability to produce a complete record of patient clinical encounters,
as well as supporting activities of other treatments that relate directly or indirectly
through face to face, including the fact-based decision support, quality
management, and reporting the results of "Hoerbst and Ammenwerth
(http://mhcc.maryland.gov, accessed on October 29, 2010).
It is important to note that an Electronic Health Record is produced and
maintained its use by an agency, such as hospitals, physician clinics, or health
center. An Electronic Health Record is not a long record of all care provided to
patients in all places from time to time. Length of patient records can be stored in
a national health system or information that is regional.
Electronic Health Record largely designed to combine data from a large
support services, such as pharmacy, laboratory, and radiology, with various
components of clinical care (such as care plans, medication administration
records, and doctor's instructions).
Registration, receipts, revenues, and transfers (Registration, Admission,
Discharge and Transfer) data is a key component of the Electronic Health Record.
These data include important information for patient identification and accurate
assessment, but not necessarily limited to, name, demographics, immediate
family, workplace information, chief complaint, patient disposition, etc.
Registration section of the Electronic Health Record contains the unique patient

identifier, usually consisting of numeric or alphanumeric sequence that can be

identified outside organizations or institutions that serve. Data RADT allows
individual health information is collected for use in clinical analysis and research.
Unique patient identifier is the essence of an Electronic Health Record and link all
clinical observations, tests, procedures, complaints, evaluation, and diagnosis of
patients. This identifier is sometimes referred to as medical record number or
master patient index (Master Patient Index). Advances in automated information
systems have made it possible for organizations or institutions to use the
company's extensive patients master index, the so-called enterprise-wide master
patient Indices.
Laboratory systems are generally self-contained system which is
connected to the Electronic Health Record. Typically, there is a laboratory
information system (Laboratory Information Systems) used as a liaison to
integrate command, the results of laboratory instruments, scheduling, billing, and
other administrative information. Laboratory data bit is fully integrated with the
Electronic Health Record. Even when the LIS conducted by the same vendor as
the Electronic Health Record, many machines and analysis used in the process of
diagnostic laboratories that are not easily integrated into the Electronic Health
Record.
Radiology information system (Radiology Information Systems) is used
by radiology departments to contain radiological data of patients (e.g., doctor's
instructions, interpretation, patient identification information) and images. RIS
includes patient tracking, scheduling, reporting of results, and image tracking
function. RIS system is usually used in conjunction with picture archiving
communication. Some pharmacies have computerized well, like a robot in the
making recipes. Usually, these systems are not integrated in the Electronic Health
Record.
Computerized Physician Order Entry (CPOE) allows providers to
electronically clinical laboratory orders, pharmacy, and radiology services. CPOE
systems offer a variety of functions, from the ability of ordering its own
prescription for a more sophisticated system such as ordering additional services

complete, reminders, a customized set of orders, and reporting results.

Clinical Documentation in the Electronic Health Record includes:
a. Doctors, nurses and other clinicians record
b. Flow sheets that contain vital signs, input and output, a list of problems, MARS
c. Note per-operative
d. Discharge summary
e. Transcription of document management
f. Abstract medical records
g. Advance Directive
h. Power of attorney for health decisions
i. Approval (procedural)
j. Medical record / chart tracking
k. Release of information (including authorization)
l. Staff credentialing / qualifications of staff and contract documentation
m. Tracking chart deficiencies
n. Utilization management
To sum up, standardization of the classification in nursing care is very
important, especially if we talk in terms of computerization. Agreement terms and
terminology will improve the communication process, eliminating the ambiguity
of documentation and provide further benefits to the system of compensation,
scheduling, evaluation of the effectiveness of interventions or until the means of
identifying errors in nursing management. One of the major challenges in health
informatics is a standard agreement on classification and terminology that covers
the various concepts (medicine, nursing, laboratory, medicine, patient safety,
images, data exchange, demographic) (Lee Seon ah, 2010).

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III. Conclusion
From the description above may be assembled linkage importance of
process documentation, ability to adopt IT technology for nurses, and quality of
nursing services both at the unit level and even hospitals. IT helps to increase
efficiency and effectiveness of documentation, while nurses have a major role in
dealing with patients, so the program is achieved with maximum care.
Documentation is the written information that describes the service
nursing and medical given to clients. Nursing documentation clearly describes the
assessment of the client's health status, nursing interventions services provided
and the results to the client's health status. The results of these studies prove that
IT programs delivering quality nursing care through the process technology-based
documentation.
For recommendation, IT training is required to nurses in order to
understand documentation and implement effective IT program and the need for
research further to understand the effectiveness of these tools in improving the
health status of clients and reduction in hospitalization costs. Electronic Health
Record is essential for development in the health care sector, including in
Indonesia. Great usefulness is very important to be a consideration by policymakers to better facilitate the procurement of software, maintenance, personnel
training for implementing and developing this electronic health record.
There are several things to consider in the use of Electronic Health
Record, that is common language used in the program and looks, coding, varied
program settings that are used in every hospital, disagreements within the groove
of protocol program until the problems of perception, motivation, attitude and
ability of nurses in various institutions.
The use of computerized patient records are growing rapidly, requiring a
standardized language in describing the problems of patients. Nursing diagnoses
complement those needs and help define the scope of nursing practice, by
describing the condition of nurses who can treat independently. Nursing diagnoses
include critical thinking and decision making, and provides terms that are
universally understood and consistently among the nurses who work in various

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places, including hospitals, outpatient clinics, other care facilities, occupational

health facilities, and private practice/private.
In conclusion, nursing profession as one of individual health services has a
very vital responsibility. It is represented to support the client's care during the
healing period. To achieve the goals, the nurse should pay attention for important
processes in this profession, such as documentation, information technology
adoption, nursing process and quality because these steps determine the
professionalism.

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