Konversi Dokumentasi Keperawatan Berbasis Elektronik
Abstract
This research aims to improve the quality of nursing services, increase time and cost efficiency, optimize patient data management, improve care coordination, and provide better outcomes for patients overall. The method used was a systematic review carried out using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) method. The databases used are Scopus, Science Direct, Pubmed and the Ners journal. The research results show that electronic-based documentation offers optimization for nurses in providing nursing care to patients. This includes more effective and efficient documentation, more integrated nursing care, and reducing the use of paper (paperless) which can contribute to reducing the impact of global warming and reducing hospital expenditure. In conclusion, changing nursing documentation in paper form to electronic documentation in hospitals requires careful preparation. Preparation for preparing the instruments used, supporting infrastructure and the readiness of nurses to carry out nursing documentation.
Keywords: Nursing Documentation,Electronic Nursing Documentation
References
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Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2020). Unsafe Nursing Documentation: a Qualitative Content Analysis. Nursing Ethics, 27(5), 1213–1224. https://doi.org/10.1177/0969733019871682
Anderson, I., Furukawa, M., Mayer, L., & Selsky, S. (2023). Engaging Frontline Nurses in Building an Electronic Workload Acuity Tool. Nurse Leader, 21(3), 401–404. https://doi.org/10.1016/j.mnl.2023.02.012
Aris Winata, I. M. N., & Hariyati, R. T. S. (2021). Nurse Satisfaction Level Using Electronic Nursing Documentation. Enfermeria Clinica, 31, S109–S112. https://doi.org/10.1016/j.enfcli.2020.12.002
Chan, K. G., Pawi, S., Ong, M. F., Kowitlawakul, Y., & Goy, S. C. (2020). Simulated Electronic Health Documentation: a Cross-Sectional Exploration of Factors Influencing Nursing Students’ Intention to Use: Simulated Electronic Health Documentation. Nurse Education in Practice, 48(August), 102864. https://doi.org/10.1016/j.nepr.2020.102864
Dai, L., Wu, Z., Pan, X., Zheng, D., Kang, M., Zhou, M., Chen, G., Liu, H., & Tian, X. (2024). Design and Implementation of an Automatic Nursing Assessment System Based on CDSS Technology. International Journal of Medical Informatics, 183(November 2023), 105323. https://doi.org/10.1016/j.ijmedinf.2023.105323
Dos Santos, K. B., Campos, C. S., de São José Perrone, A. C. A., de Araújo Silva Vieira, C. M., Coelho, D. P., Hallack-Neto, A. E., Lockwood, C., & de Araújo Püschel, V. A. (2020). Nursing Documentation for Chemotherapy in A University Hospital’s Bone Marrow Transplant Unit: a Best Practice Implementation Project. International Journal of Evidence-Based Healthcare, 18(1), 75–85. https://doi.org/10.1097/XEB.0000000000000216
Holub, M., & Giegerich, C. A. (2023). Decreasing the Nursing Documentation Burden During the Covid-19 Surge. Nurse Leader, 21(1), 38–41. https://doi.org/10.1016/j.mnl.2022.11.006
Jepsen, J. H., Hellerup, M., & Specht, K. (2022). Orthopaedic Nurses’ Experiences with Real-Time Documentation in A High-Tech Ward: a Qualitative Study. International Journal of Orthopaedic and Trauma Nursing, 44, 100901. https://doi.org/10.1016/j.ijotn.2021.100901
Laukvik, L. B., Lyngstad, M., Rotegård, A. K., & Fossum, M. (2024). Utilizing Nursing Standards in Electronic Health Records: a Descriptive Qualitative Study. International Journal of Medical Informatics, 184(September 2023). https://doi.org/10.1016/j.ijmedinf.2024.105350
Lias, N., Lindholm, T., Holmström, A.-R., Uusitalo, M., Kvarnström, K., Toivo, T., Nurmi, H., & Airaksinen, M. (2024). Harmonizing the Definition of Medication Reviews for Their Collaborative Implementation and Documentation in Electronic Patient Records: a Delphi Consensus Study. Research in Social and Administrative Pharmacy, September 2023. https://doi.org/10.1016/j.sapharm.2024.01.016
Mykkänen, M., Kinnunen, U. M., Liljamo, P., Ahonen, O., Kuusisto, A., & Saranto, K. (2022). Using Standardized Nursing Data for Knowledge Generation – Ward Level Analysis of Point of Care Nursing Documentation. International Journal of Medical Informatics, 167(March). https://doi.org/10.1016/j.ijmedinf.2022.104879
Nantschev, R., & Ammenwerth, E. (2022). Challenges Using Electronic Nursing Routine Data for Outcome Analyses: A Mixed Methods Study. International Journal of Nursing Sciences, 9(1), 92–99. https://doi.org/10.1016/j.ijnss.2021.11.003
Ng, L., Osborne, S., Eley, R., Tuckett, A., & Walker, J. (2024). Exploring Nursing Students’ Perceptions on Usefulness, Ease of Use, and Acceptability of Using A Simulated Electronic Medical Record: A descriptive study. Collegian, 31(2), 120–127. https://doi.org/10.1016/j.colegn.2023.12.006
Ojo, I. O., & Olaogun, A. A. (2023). Utilisation and Challenges of Standardised Nursing Languages in Nursing Process Booklets in Selected Tertiary Health Institutions in Nigeria. International Journal of Africa Nursing Sciences, 18(December 2022), 100552. https://doi.org/10.1016/j.ijans.2023.100552
Saraswasta, I. W. G., & Hariyati, R. T. S. (2021). A Systematic Review of The Implementation of Electronic Nursing Documentation Toward Patient Safety. Enfermeria Clinica, 31, S205–S209. https://doi.org/10.1016/j.enfcli.2020.12.023
Schnock, K. O., Kang, M. J., Rossetti, S. C., Garcia, J., Lowenthal, G., Knaplund, C., Chang, F., Albers, D., Korach, T. Z., Zhou, L., Klann, J. G., Cato, K., Bates, D. W., & Dykes, P. C. (2021). Identifying Nursing Documentation Patterns Associated with Patient Deterioration and Recovery from Deterioration In Critical and Acute Care Settings. International Journal of Medical Informatics, 153(June), 104525. https://doi.org/10.1016/j.ijmedinf.2021.104525
Siegert, T., Eberl, I., & Göhlich, M. (2021). Organizational Learning in Hospitals: Evaluation of The Implementation of IT-Supported Nursing Documentation. Zeitschrift Fur Evidenz, Fortbildung Und Qualitat Im Gesundheitswesen, 161, 1–8. https://doi.org/10.1016/j.zefq.2021.01.002
Su, J. J., Masika, G. M., Paguio, J. T., & Redding, S. R. (2020). Defining Compassionate Nursing Care. Nursing Ethics, 27(2), 480–493. https://doi.org/10.1177/0969733019851546
Sutton, D. E., Fogel, J. R., Giard, A. S., Gulker, L. A., Ivory, C. H., & Rosa, A. M. (2020). Defining an Essential Clinical Dataset for Admission Patient History to Reduce Nursing Documentation Burden. Applied Clinical Informatics, 11(3), 464–473. https://doi.org/10.1055/s-0040-1713634
Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2020). Unsafe Nursing Documentation: a Qualitative Content Analysis. Nursing Ethics, 27(5), 1213–1224. https://doi.org/10.1177/0969733019871682
Published
2024-04-01
Section
Articles
Copyright (c) 2024 Siti Kalimah, Rizki Fitryasari P.K, Herdina Mariyanti
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