Title: Nursing documentation - Wikipedia
Headings: Nursing documentation
Nursing documentation
Contents
Purposes
Documentation of the nursing process
Content
Admission
Assessment
Nursing care plan
Progress notes
Recording format
Paper-based nursing documentation
Electronic nursing documentation
Comparison of the quality of paper-based and electronic documentation
Quality of nursing documentation
Standardized nursing terminology
Structured documentation
References

Content: Electronic nursing documentation
Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery. Comparison of the quality of paper-based and electronic documentation
Electronic nursing documentation systems are able to produce somewhat better quality data in comparison with paper-based systems, in certain respects depending on the characteristics of the systems and the practice of the various study settings. The common benefits of electronic documentation systems include the improvement of comprehensiveness in documenting the nursing process, the use of standardized language and the recording of specific items about particular client issues and relevance of the message. In addition, electronic systems can improve legibility, dating and signing in nursing records. For the documentation of nursing assessment, the electronic systems significantly increased the quantity and comprehensiveness of documented assessment forms in each record. In regard to the NCP, the electronic standardized NCPs were graded with a higher total quality score than its paper-based counterpart. In addition, in comparison with the paper-based documentation systems, the electronic systems, due to their automatic functions, were able to improve the format, structure and process features of documentation quality such as legibility, signing, dating, crossing out error and space with a single line and resident identification on every page. Paper-based documentation has been found to be inferior in comparison with electronic documentation. This is caused by the inherent nature of paper being difficult to update, time-consuming in a recording.