OPPORTUNITIES AND CHALLENGES IN USING ELECTRONIC HEALTH RECORDS DATA
Main Article Content
Keywords
electronic health records and audit instruments, paper-based, process, quality of nursing documentation, structure
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 records. 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.
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Feras Saleh Dhaifallah Alsahli
Sociology King Salman Medical Madinah
Ahmad Obaid Muneer Alootibi
Health services administration Afif General Hospital Afif
Aber Mazal Alshmmear
Healthy Assistant Mental Health Hospital Hafar Al-Batin
Suad Athal Adad Alenezy
Alnadhem north primary health care Nurse Riyadh
Rania Bandar Alroais
Nursing specialist second cluster Riyadh
Sader Faleh M Almutairy
Health Administration Ruh-phcc-westyarmuk Riyadh
Tahani Ali Alqahtani
Hospital Administration Ruh-phcc-westyarmuk Riyadh
Jawaher Fahad Almutairi
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