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IMPLEMENTATION OF ELECTRONIC-BASED NURSING DOCUMENTATION TOWARDS PATIENT SAFETY: SYSTEMATIC REVIEW
Last modified: 2019-09-16
Abstract
AbstractsIntroduction: Nursing documentation is considered as a part of nursing care. Most of the nurses only fulfill 50% or less than 80% of the total documentation target required, which indicates the deficient level of nursing care quality. The advanced technology of information regarding to medical service is expected to increase the quality of documentation which eventually improve the patient safety. Objective: to understand the implementation of electronic-based nursing care documentation (EHR) towards patient safety. Method: The method used in this study is a systematic review. The online journal database used is sourced from Science Direct, PROQUEST, Scopus, Wiley Online and Emerald insight for 5182 journal article. Results: 20 articles were included in the final review. The study shows that the implementation of EHR affects the six goals of patient safety. Data in EHR helps to identify patients correctly and improve the effective communication. The implementation of medication errors prevention guidance could increase the safety of medicines considered as High-Alert, ensure the correct location of surgery, and reducing the risk of infection. In addition, it also reduces the risk of injury of falling by screening for patients at risk. Conclusion: Optimizing the implementation of electronic nursing documentation affects the quality of nursing documentation and patient safety. Keywords: electronic nursing documentation, EHR, patient safety