Related Experiment Video
Updated: Oct 28, 2025

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients
Published on: July 12, 2024
Using Electronic Software for Nursing Documentation in Nursing Students
Kamran Ranjbar1, Raheleh Sabetsarvestani2, Hossein Oghlaee3
1Fasa University of Medical Sciences, Fasa, Iran.
Aim:
This study aimed to assess the effect of using electronic software for nursing documentation on students.
Method:
A quasi-experimental study was performed. The study population comprised 80 nursing students who were randomly divided into 2 groups. The software used for nursing documentation was designed according to the nursing process model. Students in the experimental group received theoretical and practical training. The control group attended a 1-day course on the nursing process model. A questionnaire was used to assess student satisfaction in nursing documentation. The data were analyzed using the Statistical Package for Social Sciences software 16 (Chicago, USA). The standard and comprehensiveness of documentation were analyzed using the summative content analysis with the MaxQDA 10 software (USA). TREND statement was followed for reporting.
Results:
The analysis showed that the mean scores of satisfaction in both groups increased significantly (p < .05). Furthermore, the result of the summative content analysis showed that the comprehensiveness and the standard of nursing documentation increased significantly in the experimental group (p < .05).
Conclusion:
The findings confirmed the usefulness of electronic software in improving the standard and comprehensiveness of nursing documentation and the students' satisfaction.
Related Concept Videos
Methods of Documentation VII: EMR
Role of Communication in the Nursing Process III: Evaluation and Documentation
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
Guidelines 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.
Legal Guidelines for Documentation
Documentation 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...

