Journal of Modern Medical

Dear Editor
Nurses spend most of their work time on documentation [1]. Nursing reports includes the results of care and patient response. The proper reporting can indicate the appropriateness of the services provided. Incomplete nursing report can endanger the safety of the patient and the position of the nurse [2, 3]. Today, with the development of nursing care, the amount of nursing reports has increased [4]. On the other hand, most nurses express a positive attitude towards electronic documentation of nursing reports [5]. Electronic nursing documentation is an essential aspect of inpatient care and interdisciplinary communication [6]. The amount of time saved by electronic documentation can be devoted to patient care activities. Modification of documentation practices is beneficial due to reducing workload and improving quality and employee satisfaction [7]. Studies conducted in Iran have shown that nursing documentation does not comply with standards. Studies that compared international standards with national standards showed that nurses in other countries are more diligent in observing the principles and standards of nursing documentation [8, 9, 10]. The properly developed system for documenting patient care in nursing care programs should have a legal, ethical, and professional framework [9].
Despite the positive effects of nursing documentation on the treatment system including increased productivity and efficiency of nurses, the save of time, reduced tensions caused by spending a lot of time on documentation (such as stress and anxiety), quick charting of the patient’s clinical condition, increased concentration and satisfaction of nurses, the possibility of analyzing information and plotting the treatment procedures of the patient, increased interdisciplinary communication in therapeutic settings, many developments in information technology and computer engineering infrastructures, the presence of postgraduate personnel from related fields, the possibility of adding creative ideas to documentation based on global conditions, the position of nursing documentation in Iran’s hospital information system has been neglected so far. Considering the increasing progress of technology and the speed of communication and turning into an inseparable part of young people’s lives, the traditional nursing documentation is not compatible with the current conditions of in the new generation of nursing graduates. It seems that, with the arrival of the time to apply macro-policies, the implementation of electronic nursing documentation in the hospital information system can lead to positive outcomes.

References

1. Olivares Bøgeskov B, Grimshaw-Aagaard SLS. Essential task or meaningless burden? Nurses’ perceptions of the value of documentation. Nord J Nurs Res. 2019; 39(1):9-19. [DOI:10.1177/2057158518773906]
2. Jasemi M, Zamanzadeh V, Rahmani A, Mohajjel A, Alsadathoseini F. Knowledge and practice of Tabriz teaching hospitals’ nurses regarding nursing documentation. Thrita. 2013; 2(2):e93657. [DOI:10.5812/thrita.8023]
3. Varzeshnezhad M, Rassouli M, Tafreshi MZ, Ghorbanpour RK, Moss J. Transcultural mapping and usability testing of the clinical care classification system for an iranian Neonatal ICU Population. Comput Inform Nurs. 2014; 32(4):182-8. [DOI:10.1097/CIN.0000000000000032] [PMID]
4. Cherry BJ, Ford EW, Peterson LT. Experiences with electronic health records: Early adopters in long-term care facilities. Health Care Manage Rev. 2011; 36(3):265-74. [DOI:10.1097/HMR.0b013e31820e110f] [PMID]
5. Raddaha A, Obeidat A, Awaisi H, Hayudini J. Opinions, perceptions and attitudes toward an electronic health record system among practicing nurses. J Nurs Educ Pract. 2017; 8(3):12. [DOI:10.5430/jnep.v8n3p12]
6. Shala DR, Jones A, Fairbrother G, Tran D. Completion of electronic nursing documentation of inpatient admission assessment: Insights from Australian metropolitan hospitals. Int J Med Inform. 2021; 156:104603. [DOI:10.1016/j.ijmedinf.2021.104603] [PMID]
7. Lindsay MR, Lytle K. Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Appl Clin Inform. 2022; 13(3):711-9. [DOI:10.1055/a-1868-6431] [PMID]
8. Ranjbar K, Sabetsarvestani R, Oghlaee H, Sarvestani PS, Dehghan A, Shirazi ZH. Using electronic software for nursing documentation in nursing students. Florence Nightingale J Nurs. 2021; 29(2):128-36. [DOI:10.5152/FNJN.2021.20077] [PMID]
9. Shafiee M, Shanbehzadeh M, Nassari Z, Kazemi-Arpanahi H. Development and evaluation of an electronic nursing documentation system. BMC Nurs. 2022; 21(1):15. [DOI:10.1186/s12912-021-00790-1] [PMID]
10. Saravi BM, Asgari Z, Siamian H, Farahabadi EB, Gorji AH, Motamed N, et al. Documentation of medical records in hospitals of Mazandaran university of medical sciences in 2014: A quantitative study. Acta Inform Med. 2016; 24(3):202. [DOI:10.5455/aim.2016.24.202-206] [PMID] [PMCID]