The Impact of Information Technology on Electronic Record Making and Improving Nursing Processes

Introduction: The process of recording clinical documents as one of the key roles of nurses and an effective tool in recording the patient's clinical condition, individual needs and patient response to care and is a way to communicate with the treatment team and use the patient's experiences. Due to the dramatic emergence of information systems and technology, researchers intend to investigate the impact of information technology on electronic filing and improving nursing processes.Methods: The present study is a review that was conducted in 1399 and according to the keyword search EHR, Documentation, Electronic Health Record, Computerized Medical Record, Nursing Care, electronic file making and nursing care in PubMed, Elsevier, Sid and Motor databases Google Scholar search was performed using Boolean (AND / OR) expressions. The search for resources was carried out from June to July 2016. Inclusion criteria were based on their relevance to the purpose of the study, free access to the study, the period of publication of the study from 2010 to 2020, and the language of publication of the study was Persian or English. Finally, the selected articles were reviewed again by researchers.Results: After completing the search of 24 articles, 11 articles were included in the study by applying inclusion criteria. In four areas: reviewing nurses' views and satisfaction (4 articles), reviewing leading opportunities and threats (5 articles), effective factors in admission (( (3 articles) and assessed the needs of nurses (2 articles) examined the issues: the emphasized aspects of the articles include clinical intelligence (54%), clinical exchange of information (63%), increasing safety and speed of work (72%), achieving integration In the whole system (63%) and cost savings and ease of collecting and processing information in managerial decisions (54%).Conclusion: According to the findings of this study, it was found that the use of information technology systems such as patient bed terminal systems, optical pen and digital personal assistant using speech recognition technologies, barcode system, scanning technology and structural forms and templates with the possibility of implementation Clinical intelligence in treatment decisions and the possibility of reducing errors and increasing safety and speed and solving challenging issues such as insufficient equipment, the possibility of poor system design, the possibility of not receiving adequate training and staff resistance to acceptance and adaptation to the new system can have a potential impact on improvement. Nursing processes and finally the implementation of electronic records were witnessed.

کلیدواژه ها:

EHR ، Documentation ، Electronic Health Record ، Computerized Medical Record ، Nursing Care ، Electronic Record Making and Nursing Care.