Paper-based records and electronic medical records (EMRs) differ in content, documentation process and structure, according to a study published in the Journal of Clinical Nursing.
Proper documentation of patient care is key in providing accurate and high-quality care to patients. As implementation of EMRs continues to expand, researchers set out to compare the quality of paper-based and electronic-based health records in terms of content, process and structure.
The study compared 434 paper and EMRs each from medical and surgical wards to evaluate nursing documentation. Results showed EMRs were more accurate in process and structure, but paper-based records maintained a higher quantity and quality of content. Researchers concluded the low quality of nursing documentation and lack of knowledge and skills affected both paper and EMR documentation.
“Both forms of documentation revealed drawbacks in terms of content, process, and structure,” concluded first author Laila Akhu-Zaheya, PhD, RN, of the Jordan University of Science and Technology, and colleagues. “Policies and actions to ensure quality nursing documentation at the national level should focus on improving nursing knowledge, competencies, practice in nursing process, enhancing the work environment and nursing workload, as well as strengthening the capacity building of nurses practice to improve the quality of nursing care and patients’ outcomes.”