ISSN 2229-5984 (P)

2249-5576 (e)

Electronic Nursing Documentation

Sulakshana Chand* and Jyoti Sarin**

To Cite: Chand, S. & Sarin, J. (2014). Electronic Nursing Documentation. International Journal of Information
Dissemination and Technology, 4(4), 328-331.

*Certified Registered Nurse ABSTRACT

(Maternal Newborn Nursing)
Northside Hospital, Atlanta, GA
30071
**Director-Principal
MM College of Nursing,
MM University, Mullana (Ambala)
Corresponding Author
Jyoti Sarin
jyotisarin@yahoo.co.in
Nursing documentation has been one of the most important functions of nurses since
the time of Florence Nightingale. It is a true representation of fact or act, expressing all
actions undertaken in the care provided to the patient. Despite the importance of
nursing documentation, often the nurses' notes do not contain necessary information
to support the institution and nursing in judicial case. Handwritten documents often
omit patient's data, including care plans, interventions, outcomes, because of
inconsistent documentary methods. Incomplete medical records can hinder the
clinician's ability to access and analyze patient data. The need for quality nursing
documentation cannot be brushed aside because failure to maintain records means
failure of duty toward the patient. The fragmented nature of health care, the large
number of transactions, and the need to integrate new scientific evidence into
practice supports the advantage of electronic medical records over paper based
documents in achieving improved quality and efficiency. The use of information
technology in health care is a prominent feature of most recommendations. When the
right technology is successfully implemented, it can increase efficiency and alleviate
some of the burdens on nurses, freeing them to concentrate on direct care. Although
electronic nursing documentation has multiple benefits, its implementation raises
issues as any change in work system can have important consequences for providers
as well as patients. Despite the challenges and factors that hinder adoption of
computerized documentation, however, it is the best way ahead to meet the new
challenges and changing needs of the health care.
KeyTerms: Documentation, Nursing, computerized, Information Technology.

Received On: 19.12.13; Revised On: 09.05.14; Accepted On: 12.09.14

INTRODUCTION documentation promotes consistency in client care and effective

communication between members of the health care team1. The
Documentation is an integral part of safe and appropriate clinical
health care environment is continuously changing and evolving
practice and is a record of judgment and critical thinking used in
and nursing is not immune to these changes. The rapid expansion
professional practice1. Documentation is a fundamental nursing
of technology into every aspect of modern nursing suggests that
responsibility with professional, legal, and financial
21st century nurse must establish and maintain computer
ramifications2. Nursing documentation has been one of the most
competency. In response, nursing in radically transforming to
important functions of nurses since the time of Florence
meet the evolving and complex health care demands. The
Nightingale3. Nursing documentation is defined as, the record of
transition to computerized documentation is one technological
nursing care that is planned and given to patients by qualified
change that has significant implications for the nursing profession
nurses or by other care giver under the direction of a qualified
and the overall health care system5. Such systems relieve nurses of
nurse4. Objective, contemporaneous and relevant

International Journal of Information Dissemination and Technology | October-December 2014 | Vol. 4 | Issue 4 328
time consuming clerical duties and assist them in producing
le g ible a nd c om pr e he ns iv e pa tie nt c a r e pla ns a nd
documentation.
NEED
Nursing documentation continues to draw criticism from
professional, community, and regulatory organizations because
of incomplete, substandard charting practices6. Handwritten
documents often omit patient's data, including clinical problems
or care plans, interventions, and especially outcomes 7 .
Inconsistent and incomplete documents sabotage the medical
records to be reliable and valid resource of information8.
Most commonly observed problems with documentation
include; poor record-keeping; poor planning of care; incomplete
admission records; lack of documented care planning; failing
systems of communication; ad hoc recording of vital
observations; compromised fluid management; lack of reported
care evaluation 9. Other problems in nursing documentation
include; disruption, incomplete and inappropriate charting10.
Quite often, complaints arising from clinical incidents lead to
indefensible claims due to lack of thorough documentation and
accountability9. Therefore, standardization of nursing records is
important with regards to adequacy of formal language, grammar,
accuracy, brevity, clarity, identification and technical
terminology11. Computerized documentation can assist nurses in
addressing problems that occur as a result of paper-based
documentation thus enabling nurses to fulfill multifaceted roles
and consequently enhance the quality and efficiency of nursing
practice. It can also improve the accuracy and
comprehensiveness of patient information and enhance the
provision of quality nursing care.
COMPUTERIZED HEALTH RECORDS
Although methods of charting have evolved overtime to meet the
changing needs in healthcare12. Radical changes came with the
introduction of computers in the healthcare in the late 20th
century. Department of Family Medicine at University of South
Carolina was one of the first known organizations to develop and
use a computerized medical record in 1972. By the early nineties,
the idea of widespread electronic medical records
implementation was on the horizon. Health care information
technology planners realized that the next logical step for health
information system was a completely integrated computerized
medical record13. The health industry is beginning to fully
appreciate the complexity of integration required to achieve
comprehensive computerized health record.
ADVANTAGES
Computerized nursing documentation has distinct advantages as
listed below.
§ Providing a single, shareable, accurate, up to date, rapidly
retrievable patient data14.
§ Reducing documentation redundancies15.
§ Facilitating use of structured tools for assessment as a basis
for setting priorities and deciding the appropriate nursing
interventions.
329 International Journal of Information Dissemination and Technology | October-December 2014 | Vol. 4 | Issue 4
§ Enhancing patient safety by reducing medical errors16.
§ Facilitating prompt decision making by providing quick
access to patient information and decision support system.
§ Minimizing the potential of lost/damaged information.
§ Reducing duplication of diagnostic evaluation and risk of
treatment delay.
§ Enhancing continuity of care.
§ Protecting patient's privacy
§ Providing access to patient information by multiple users at
one point of time.
§ Improves communication, exchange of information and
coordination; among nurses; between nurses and members
of health care team; between different health care facilities.
§ Facilitates clinical nursing audits.
§ Reduces cost by consolidating patient data in one place and
eliminating the need for maintenance and storage of paper
records.
§ Assists in meeting regulatory and legal documentation
requirements by improving the accuracy of patient
information.
§ Improves nurse productivity, patient satisfaction, and overall
success of health care institution
§ Facilitates data mining for quality assurance and research
purposes.
§ Enables epidemiological monitoring and disease
surveillance14.
Despite existing evidence that supports the benefits of
computerized documentation, the transition from paper-based to
computerized documentation still presents major challenges
within health care organizations.
CHALLENGES
Embracing computerized health record technology is a daunting
task even for those who accredit themselves to be computer savvy
individuals. Notions of apprehension and fear of a paperless
system is brought to the fore front by those who are deemed to
commission the computerized health record technology17. Its
implementation is a course of action that requires much time and
attention. Transition to computerized documentation creates
stress, uncertainty and role confusion. Although computerized
nursing documentation can be very beneficial, barriers exist that
impede its implementation5. The computerization of nursing
documentation systems necessitates both structural and
behavioral change18. Since nurses are often resistant to change,
the implementation of computerized documentation can be a
very challenging endeavor19. Lack of nurses' acceptance and their
attitude has been cited factors that hinder computerized health
record implementation. Widespread implementation of
computerized health records can also been hampered by;
technical matters; financial matters - particularly applicable to
non-publicly funded health service systems; resources issues,
training and re-training; resistance by potential users; implied
time consuming clerical duties and assist them in producing
le g ible a nd c om pr e he ns iv e pa tie nt c a r e pla ns a nd
documentation.
NEED
Nursing documentation continues to draw criticism from
professional, community, and regulatory organizations because
of incomplete, substandard charting practices6. Handwritten
documents often omit patient's data, including clinical problems
or care plans, interventions, and especially outcomes 7 .
Inconsistent and incomplete documents sabotage the medical
records to be reliable and valid resource of information8.
Most commonly observed problems with documentation
include; poor record-keeping; poor planning of care; incomplete
admission records; lack of documented care planning; failing
systems of communication; ad hoc recording of vital
observations; compromised fluid management; lack of reported
care evaluation 9. Other problems in nursing documentation
include; disruption, incomplete and inappropriate charting10.
Quite often, complaints arising from clinical incidents lead to
indefensible claims due to lack of thorough documentation and
accountability9. Therefore, standardization of nursing records is
important with regards to adequacy of formal language, grammar,
accuracy, brevity, clarity, identification and technical
terminology11. Computerized documentation can assist nurses in
addressing problems that occur as a result of paper-based
documentation thus enabling nurses to fulfill multifaceted roles
and consequently enhance the quality and efficiency of nursing
practice. It can also improve the accuracy and
comprehensiveness of patient information and enhance the
provision of quality nursing care.
COMPUTERIZED HEALTH RECORDS
Although methods of charting have evolved overtime to meet the
changing needs in healthcare12. Radical changes came with the
introduction of computers in the healthcare in the late 20th
century. Department of Family Medicine at University of South
Carolina was one of the first known organizations to develop and
use a computerized medical record in 1972. By the early nineties,
the idea of widespread electronic medical records
implementation was on the horizon. Health care information
technology planners realized that the next logical step for health
information system was a completely integrated computerized
medical record13. The health industry is beginning to fully
appreciate the complexity of integration required to achieve
comprehensive computerized health record.
ADVANTAGES
Computerized nursing documentation has distinct advantages as
listed below.
§ Providing a single, shareable, accurate, up to date, rapidly
retrievable patient data14.
§ Reducing documentation redundancies15.
§ Facilitating use of structured tools for assessment as a basis
for setting priorities and deciding the appropriate nursing
interventions.
329 International Journal of Information Dissemination and Technology | October-December 2014 | Vol. 4 | Issue 4
§ Enhancing patient safety by reducing medical errors16.
§ Facilitating prompt decision making by providing quick
access to patient information and decision support system.
§ Minimizing the potential of lost/damaged information.
§ Reducing duplication of diagnostic evaluation and risk of
treatment delay.
§ Enhancing continuity of care.
§ Protecting patient's privacy
§ Providing access to patient information by multiple users at
one point of time.
§ Improves communication, exchange of information and
coordination; among nurses; between nurses and members
of health care team; between different health care facilities.
§ Facilitates clinical nursing audits.
§ Reduces cost by consolidating patient data in one place and
eliminating the need for maintenance and storage of paper
records.
§ Assists in meeting regulatory and legal documentation
requirements by improving the accuracy of patient
information.
§ Improves nurse productivity, patient satisfaction, and overall
success of health care institution
§ Facilitates data mining for quality assurance and research
purposes.
§ Enables epidemiological monitoring and disease
surveillance14.
Despite existing evidence that supports the benefits of
computerized documentation, the transition from paper-based to
computerized documentation still presents major challenges
within health care organizations.
CHALLENGES
Embracing computerized health record technology is a daunting
task even for those who accredit themselves to be computer savvy
individuals. Notions of apprehension and fear of a paperless
system is brought to the fore front by those who are deemed to
commission the computerized health record technology17. Its
implementation is a course of action that requires much time and
attention. Transition to computerized documentation creates
stress, uncertainty and role confusion. Although computerized
nursing documentation can be very beneficial, barriers exist that
impede its implementation5. The computerization of nursing
documentation systems necessitates both structural and
behavioral change18. Since nurses are often resistant to change,
the implementation of computerized documentation can be a
very challenging endeavor19. Lack of nurses' acceptance and their
attitude has been cited factors that hinder computerized health
record implementation. Widespread implementation of
computerized health records can also been hampered by;
technical matters; financial matters - particularly applicable to
non-publicly funded health service systems; resources issues,
training and re-training; resistance by potential users; implied
changes in working practices14; certification, security; privacy,
confidentiality and access rights; doubts on clinical usefulness;
incompatibility between systems; ethical, legal and technical
issues linked to accuracy. Computerized documentation can lead
to loss of human touch which still remains one of the vital
components of nursing care. Because of the lack of flexibility of
many computerized reporting systems, cases of wrong
classification of patients and their conditions have been reported.
Despite these barriers, there still exists intensive support for
computerization. These barriers may be minimized by;
§ Clearly communicating to nurses the need for change from
paper to computer based documentation.
§ Communicating the benefits of computerized
documentation in terms of nurses improved performance,
time saving and improved quality of nursing care.
§ Involving nurses in the change process from conception to
post implementation of computerized documentation. .
§ Training program for nurses regarding computerized nursing
documentation that is tailored to their needs and
competency level.
§ Continuous updating, hand holding, evaluation and
feedback.
§ Recognition and rewards for nurses who aptly adapt to
computerized nursing documentation.
§ Ensuring privacy and security of patient information by;
Emphasis on non-sharing of passwords
§ Access of patient information to authorized persons only.
§ Encryption of information so that it cannot be read by an
unauthorized viewer.
CONCLUSION
Record keeping is an essential part of nursing practice and is
linked with improvements in patient care. The quality of nursing
documentation has consistently been found to be failing to meet
recommended standards, thus hampering efforts to ensure
continuity of care. Incontrovertible evidence has increasingly
shown that current systems are not delivering sufficiently safe,
high quality, efficient and cost effective health care, and that
computerization, with the electronic medical records at the
centre, is effectively the only way forward. Computerized health
records represent a huge opportunity to improve patient care and
health system operations. However, it is based on carefully
constructed set of systems that are highly integrated and require
significant investment of time, money, process change and
human factor reengineering. Although computerized nursing
documentation has its own challenges, yet, it can provide
uniformity in documentation of nursing activities across the
health care organization. The benefits certainly outweigh the
risks. Despite the fact that there exist certain challenges and
factors that hinder adoption of computerized documentation,
however, it is the best way ahead to meet the new challenges and
changing needs of the health care.
International Journal of Information Dissemination and Technology | October-December 2014 | Vol. 4 | Issue 4
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