Effect of electronic report writing on the quality of nursing report recording
Journal Title: Electronic Physician - Year 2017, Vol 9, Issue 10
Abstract
BACKGROUND AND AIM: Recording performed nursery actions is one of the main chores of nurses. The findings have shown that recorded reports are not qualitatively valid. Since electronic reports can be regarded as a base to write reports, this study aims at determining the effect of utilizing electronic nursing reports on the quality of the records. METHODS: This quasi-experimental study was conducted with the aim of applying an electronic system of nursing recording in the heart department of Shahid Rahimi Medical Center, Lorestan University of Medical Science. The samples were nursing reports on the hospitalized patients in the heart department, the basis of complete enumeration (census) during the fall of 2014. The subjects were sixteen employed nurses. To do the study, the software of nursing records was set based on the Clinical Care Classification system (CCC). The research's tool was the checklist of the Standards of Nursing Documentation. RESULTS: The findings indicated that before and after the intervention, the amount of reports' adaption with the written standards, respectively, was (21.8%) and (71.3%), and the most complete recording was medicine status (58%) and (100%). The worst complete recording before the intervention, acute changes was (99.1%) and nursing processes was (78%) and after, the medicine status, intake and output status and patient's education (100%); while the nursing report structure was regarded in all cases (100%). The results showed that there is a significant difference in the quality of reporting before and after using CCC (p<0.001). CONCLUSIONS: Since the necessary parameters for recording a standard report do exist in electronic reporting (CCC), from one point, nurses are reminded to record the necessary parts and from the other point, the system does not allow the user to shut it down unless the necessary parameters are recorded. For this reason, the quality of recorded reports with electronic reporting improves
Authors and Affiliations
Khadijeh Heidarizadeh, Maryam Rassouli, Houman Manoochehri, Mansoureh Zagheri Tafreshi, Reza Kashef Ghorbanpour
Keywords
Related Articles
- EP ID EP331830
- DOI 10.19082/5439
- Views 106
- Downloads 0
Developing a conceptual model for the application of patient and public involvement in the healthcare system in Iran
INTRODUCTION: Patient and public involvement is engaging patients, providers, community representatives, and the public in healthcare planning and decision-making. The purpose of this study was to develop a model for the...
Formative evaluation of Hospital Information System According to ISO 9241-10: A case study from Iran
Introduction: Today, different information systems are operated in hospitals in Iran to manage the admission, discharge, radiology, pharmacy, accounting and other procedures. Inappropriate HIS system causes wasting of ti...
The impact of general health and social support on health promoting lifestyle in the first year postpartum: the structural equation modelling
BACKGROUND AND AIM: Postpartum is a critical period for mothers which often leads to neglect of their own health. Mothers' new responsibilities may affect their health promoting lifestyle (HPL). The aim of this study was...
A study of the relationship between gender/age and apparent diffusion coefficient values in spleen of healthy adults using diffusion-weighted magnetic resonance imaging.
Diffusion-weighted magnetic resonance imaging (DWI) systems are very effective in detecting strokes, and they also have shown significant promise in the detection of fibrosis and cirrhosis of the liver. However, such sys...
Effectiveness of intervention due to feedback on errors arising from inappropriate transportation and storage of blood bags in hospitals: a quasi-experimental study
BACKGROUND: The limited supply of red blood cells (RBCs) for transfusion has clinical implications, and can lead to the introduction of different approaches in decreasing blood wastage and the safe and effective delivery...