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

Authors

  • Maryam Rassouli PhD, Associate Professor, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Keywords:

Nursing records; Nursing process; Electronic health record; Electronic medical records; Hospital information system

Abstract

Background and Aim: Recording 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. 

Methods: This 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.

Results: The 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).

Conclusions: Since 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.

 

References

Toolabi T, Vanaki Z, Memarian R, Namdari M. Quality of nursing documentations in CCU by hospital

information system (HIS). Journal of Critical Care Nursing. 2012; 5(2): 53-62.

Meißner A, Schnepp W. Staff experiences within the implementation of computer-based nursing records in

residential aged care facilities: a systematic review and synthesis of qualitative research. BMC Med Inform

Decis Mak. 2014; 14: 54. doi: 10.1186/1472-6947-14-54. PMID: 24947420, PMCID: PMC4114165.

Varzeshnezhad M, Rassouli M, Zaghari Tafreshi M, Kashef Ghorbanpour R, Moss J. Transcultural

mappingand usability testing of the clinical care classification system for an Iranian neonatal ICU

population. Comput Inform Nurs. 2014; 32(4): 182-8. doi: 10.1097/CIN.0000000000000032. PMID:

Jasemi M, Zamanzadeh V, Rahmani A, Mohajjel A, Alsadathoseini F. Knowledge and Practice of Tabriz

Teaching Hospitals’ Nurses Regarding Nursing Documentation. Thrita. 2013; 2(2): 133-8. doi:

5812/thrita.8023.

Nasiriani K, Dehqani H, Akbari Roknabadi M. Nursing documentation requirements in coronary care unit.

Critical Care Nursing. 2014; 7(3): 132-41.

Ahmadi M, Habibi Koolaee M. Nursing Information Systems in Iran. Hakim Research Journal. 2010;

(3): 185-91.

Cherry BJ, Ford EW, Peterson LT. Experiences with electronic health records: Early adopters in long-term

care facilities. Health Care Manage Rev. 2011; 36(3): 265-74. doi: 10.1097/HMR.0b013e31820e110f.

PMID: 21646885.

Saranto K, Kinnunen UM, Kivekäs E, Lappalainen AM, Liljamo P, Rajalahti E, et al. Impacts of

structuring nursing records: a systematic review. Scand J Caring Sci. 2014; 28; 629–47. doi:

1111/scs.12094. PMID: 24245661.

Dal Sasso GTM, Barra DCC, Paese F, Almeida SRWD, Rios GC, Marinho MM, Debetio MG.

Computerized nursing process: methodology to establish associations between clinical assessment,

diagnosis, interventions, and outcomes. Rev Esc Enferm USP. 2013; 47(1): 238-45

Johnson M, Jefferies D, Nicholls D. Developing a minimum data set for electronic nursing handover. J Clin

Nurs. 2012; 21(3‐4): 331-43. doi: 10.1111/j.1365-2702.2011.03891.x. PMID: 22082347.

Kahouei M, Baba Mohammadi H, Askari Majdabadi H, Solhi M, Parsania Z, Said Roghani P, et al.

Nursing Information System: a Module of Electronic Medical Record for Patient Care in Two University

Hospitals of Iran. Meter Sociomed. 2014;26(1):30-4. PMID: 24757398, PMCID: PMC3990381.

Min YH, Park H, Chung E, Lee H. Implementation of a next-generation electronic nursing records system

based on detailed clinical models and integration of clinical practice guidelines. Healthc Inform Res. 2013;

(4): 301-6. doi: 10.4258/hir.2013.19.4.301. PMID: 24523995, PMCID: PMC3920043.

Ahmadi M, Rafii F, Hoseini F, Habibi Koolaee M. A Comparison of Nursing Data Classification Systems.

Health Information Management. 2012; 8(6): 852-60.

Moss J, Saba V. Costing Nursing Care Using the Clinical Care Classification System to Value Nursing

Intervention in an Acute-Care Setting. Comput Inform Nurs. 2011; 29(8): 455–60. doi:

1097/NCN.0b013e3181fcbe55. PMID: 21084972.

Ahmadi M, Rafii F, Hoseini F, Habibi Koolaee M, Mirkarimi A. Informational and Structural Needs of

Nursing Data Classification in Computerized Systems. Hayat. 2011; 1: 16-23.

Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed‐

method systematic review. J Adv Nurs. 2011; 67(9): 1858-75. doi: 10.1111/j.1365-2648.2011.05634.x.

PMID: 21466578.

Jefferies D, Johnson M, Griffiths R. A meta‐study of the essentials of quality nursing documentation. Int J

Nurs Pract. 2010; 16(2): 112-24. doi: 10.1111/j.1440-172X.2009.01815.x. PMID: 20487056.

Park H, Min YH, Jeon E, Chung E. Integration of evidence into a detailed clinical model-based electronic

nursing record system. Healthc Inform Res. 2012; 18(2): 136-44. doi: 10.4258/hir.2012.18.2.136. PMID:

, PMCID: PMC3402556.

Kelley TF, Brandon DH, Docherty SL. Electronic nursing documentation as a strategy to improve quality

of patient care. J Nurs Scholarsh. 2011; 43(2): 154-62. doi: 10.1111/j.1547-5069.2011.01397.x. PMID:

Mohamad Ghasaby M, Masudi Alavi N. Quality and barriers against nursing documentation in Kashan

Shahid Beheshti Hospital (2011). Mod Care J. 2013; 9(4): 336-43.

Alijanzadeh M, Mohebi Far R, Azadmanesh Y, Faraji M. The Frequency of Medication Errors and Factors

Influencing the Lack of Reporting Medication Errors in Nursing at Teaching Hospital of Qazvin University

of Medical Sciences, 2012. Journal of Health. 2015; 6(2): 169-79.

Azizi-Fini I, Adib-Hajbaghery M. Nursing Assistants, Drug Medication Errors, and Patient Safety: A New

Challenge in Iran. Nurs Midwifery Stud. 2016; 4(3): e34273. doi: 10.17795/nmsjournal34273. PMID:

, PMCID: PMC4915206.

Soltanian M, Molazem Z, Mohammadi E, Sharif F, Rakhshan M. Iranian Nurses’ Experiences on Obstacles

of Safe Drug Administration: A Qualitative Study. Glob J Health Sci. 2016; 8(10): 56009. doi:

5539/gjhs.v8n10p88. PMID: 27302450.

Khorrmmy F, Eshpala RH, Baniasadi T, Azarmehr N, Mohammady F. Prioritizing insurance deductions

factors of Shahid Mohammadi hospital inpatients records using Shannon Entropy, Bandar Abbas, Iran.

Medical Journal of Hormozgan University. 2013; 17(1): 77-82.

Moalemi S, Shams Abadi AR, Meshkani Z, Alikiani A, Kazemi Karyani A. Survey and comparison on the

causes of deduction in admitted social insurance: Bahonar and Arjmand hospital in Kerman. Iran Health

Information Management Association. 2014; 8(1): 17-24.

Saif Rabiei MA, Sedighi I, Mazdeh M, Dadras F, Shokouhee Solgi M, Moradi A. Study of hospital records

registration in teaching hospital of Hamadan University of Medical Sciences in 2009. Scientific Journal of

Hamadan University of Medical Sciences. 2010; 16(2): 45-9.

Published

2022-02-12