Electronic Nursing Documentation

Abstract

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.