Related Experiment Video
Updated: Feb 21, 2026
'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake
Published on: September 18, 2018
Quality of nursing documentation: Paper-based health records versus electronic-based health records
Laila Akhu-Zaheya1, Rowaida Al-Maaitah1, Salam Bany Hani1
1Jordan University of Science and Technology, Irbid, Jordan.
Aims And Objectives:
To assess and compare the quality of paper-based and electronic-based health records. The comparison examined three criteria: content, documentation process and structure.
Background:
Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organised within the system known as the electronic health records. Nursing documentation must be completed at the highest standards, to ensure the safety and quality of healthcare services. However, the evidence is not clear on which one of the two forms of documentation (paper-based versus electronic health records is more qualified.
Methods:
A retrospective, descriptive, comparative design was used to address the study's purposes. A convenient number of patients' records, from two public hospitals, were audited using the Cat-ch-Ing audit instrument. The sample size consisted of 434 records for both paper-based health records and electronic health records from medical and surgical wards.
Results:
Electronic health records were better than paper-based health records in terms of process and structure. In terms of quantity and quality content, paper-based records were better than electronic health records. The study affirmed the poor quality of nursing documentation and lack of nurses' knowledge and skills in the nursing process and its application in both paper-based and electronic-based systems.
Conclusion:
Both forms of documentation revealed drawbacks in terms of content, process and structure. This study provided important information, which can guide policymakers and administrators in identifying effective strategies aimed at enhancing the quality of nursing documentation.
Relevance To Clinical Practice:
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 nursing practice to improve the quality of nursing care and patients' outcomes.
More Related Videos
Related Concept Videos
01:30Methods of Documentation VII: EMR
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
01:10Documentation of Nursing Diagnosis
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:20Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...