Electronic Health Records: Quality Of Nursing Documentation: Paper‐Based Health Records Versus Electronic‐Based Health Records

Abstract

objectives: To assess and compare the quality of paper-based and electronic-based health records. The comparison examined three criteria: content, documentation process and structure.

Background: Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organized within the system known as the electronic health records. Nursing documentation must be completed at the highest standards, to ensure the safety and quality of healthcare services.

However, the evidence is not clear on which one of the two forms of documentation (paper-based versus electronic health records is more qualified.

Methods: A retrospective, descriptive, comparative design was used to address the

study’s purposes. A convenient number of patients’ records, from two public hospitals, were audited using the Cat-ch-Ing audit instrument. The sample size consisted

of 434 records for both paper-based health records and electronic health records

from medical and surgical wards.

Results: Electronic health records were better than paper-based health records in

terms of process and structure. In terms of quantity and quality content, paper based records were better than electronic health recor[1]ds. The study affirmed the

poor quality of nursing documentation and lack of nurses’ knowledge and skills in the nursing process and its application in both paper-based and electronic-based systems.

Conclusion: Both forms of documentation revealed drawbacks in terms of content,process and structure. This study provided important information, which can guide policymakers and administrators in identifying effective strategies aimed at enhancing the quality of nursing documentation.

Relevance to clinical practice: Policies and actions to ensure quality nursing documentation at the national level should focus on improving nursing knowledge, competencies, practice in nursing process, enhancing the work environment and nursing workload, as well as strengthening the capacity building of nursing practice to improve the quality of nursing care and patients’ outcomes.