The impact of clinical information systems on nursing documentation

Introduction: Nurses' documents are of special importance so that these documents are used in education, research, financial repayments, lawsuits and continuing treatment of the patient. Nurses have more responsibility for documenting the patient's treatment process because they are more present at the patient bedside than other health care teams. In this study, the role of information systems on nurses' documentation has been investigated.Methods: The search for this review study was performed in September 2020 using the keywords of documentation, electronic prescription, nurse, hospital information system, electronic health record. In this study, only English articles were reviewed without time limit, and based on the titles and abstracts of the articles, related studies were selected and their data were extracted by two researchers and entered in a researcher-made table.Results: In this study, 7 articles out of 43 articles were included in the study. 67.81% of nurses believed that clinical systems facilitate their documentation process. More than half of the participants in these studies (58.68%) acknowledged that these systems could facilitate their access to information. Contrary to popular belief, 82.09% of participants believed that these systems would speed up their documentation.Conclusion: Other benefits of electronic documentation include improved data integrity, deeper information retrieval, increased document quality, and greater readability of documents. Iranian nurses increase their workload because on the one hand they use several information systems at the same time and on the other hand they have to do manual and computer documentation. Using advanced information technologies on the one hand and integrating these information systems can solve this problem.

کلیدواژه ها:

Documentation ، Electronic Prescribing ، Nurse ، Hospital Information System ، Electronic Health Record