Quality Issues Exist for Both Paper-Based and Electronic Health Records
Poor quality of nursing documentation has been observed for both paper-based and electronic health records.
HealthDay News — Both paper-based and electronic health records (EHRs) have shortcomings in terms of quality of content, process, and structure, with poor quality of nursing documentation seen for both methods, according to a study published in the Journal of Clinical Nursing.
Laila M. Akhu-Zaheya, PhD, RN, from Jordan University of Science and Technology, and colleagues compared the quality of paper-based and electronic-based health records according to content, documentation process, and structure in a retrospective descriptive study. A total of 434 paper-based records and EHRs were audited using the Cat-ch-Ing Audit Instrument.
The researchers found that in terms of process and structure, EHRs were better than paper-based health records. Paper-based records were better than EHRs in terms of quantity and quality content. Poor quality of nursing documentation was affirmed in the study, as was nurses' lack of knowledge and skills in the nursing process and its application in both paper-based and EHR systems.
"Both forms of documentation revealed drawbacks in terms of content, process, and structure," the authors write. "This study provided important information, which can guide policymakers and administrators in identifying effective strategies aimed at enhancing the quality of nursing documentation."
Akhu-zaheya L, Al-maaitah R, Bany hani SH. Quality of nursing documentation: Paper-based health records versus electronic-based health records. J Clin Nurs. 2017. doi: 10.1111/jocn.14097