Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review

J Nurs Manag. 2019 Apr;27(3):491-501. doi: 10.1111/jonm.12727. Epub 2018 Dec 17.

Abstract

Aim: To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

Background: Electronic documentation has been recommended to improve quality care and patient safety. With the gradual move from paper-based to electronic nursing documentation internationally, there is a need to identify interventions that can effectively improve quality care and patient safety.

Evaluation: We conducted a systematic review on the effectiveness of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

Key issues: Six articles reporting on six individual studies met all eligibility criteria. They were uncontrolled pre/post intervention studies reporting positive impacts on at least one or more outcomes. Most outcomes related to documentation practice and documentation of content.

Conclusion: Some evidence from our review indicates that implementing electronic nursing documentation in acute hospital settings is time saving, reduces rates of documentation errors, falls and infections.

Implications for nursing management: A planned approach from management over time to allow nurses adapt to new electronic systems of documentation would seem a good investment in terms of efficiency of work time, possibly resulting in more time for clinical care.

Publication types

  • Systematic Review

MeSH terms

  • Documentation / methods
  • Documentation / standards*
  • Electronic Health Records / trends
  • Humans
  • Patient Safety / standards*
  • Quality of Health Care / standards*