Structuring Electronic Nursing Documentation: A Systematic Review of the Literature

Aim: Nursing documentations create an important part of health care documentations. This study was designed to investigate the literature systematically to create eff ective and reliable electronic nursing documentation.

Method: This descriptive study was performed using keywords “nursing documentation”, “nursing records”, “nursing information system”, “patient information system” from the databases of MEDLINE, Scopus, PUBMED, and Cumulative Index to Nursing and llied Health Literature (CINHL). The nursing studies selected were those published English language, from 2004-2014. 23 studies were extracted and further reviewed. These studies were examined nurse views about electronic nursing documentation and use of electronic nursing care plan.

Results: In the reviewed studies, nurses believed the importance of the electronic nursing documentation, and considered that this electronic documentation were increased quality of nursing care; but they ignored reporting. In reviewed researches, nurses slogged writing about patient history, nursing diagnosis, and outcomes-interventions; furthermore nurses often record patients’ socio- demographic characteristics, medical diagnosis, cause of hospitalization, and treatment and care. In addition nurses considered positively electronic nursing documentation utilizing classification system, and education about classification was eff ective structuring of the nursing documentation.

Conclusion: This study concluded that current literature about electronic nursing documentation, and nursing care plan. Establishing nursing information system that include nursing classification system, takes into account these researches results and recommendation about education for nurses to use these systems.