ASSESSMENT OF DOCUMENTATION AMONG NURSES USING ELECTRONIC HEALTH RECORD; A DESCRIPTIVE CROSS-SECTION STUDY

Abstract

Background: Electronic health record (RHRs) are digital systems that store, organize, and communicate patient’s healthcare data across many healthcare settings in order to improve service and coordination. Objective: This study examined HER documentation practice among nurses in a resource constrained tertiary hospital to identify patterns of electronic health records, major barriers to effective to effective documentation, and documents quality determined. Material and Methods: A quantitative cross sectional study was conducted comprised of 148 nurses from medical, surgical, intensive care unit, and emergency and pediatric departments. A standardized questionnaire was used to gather data on documentation practices, perceived barriers, and implications of HER. Variables association were studied using descriptive statistics, chi square test, t test and regression analysis. Results: Nurses recorded vital signs at a high rate (84%), however care plan adjustment (44%) and template usage (37%). Workload (60%), and system usability issues affected performance, especially among novice (p< 0.001) and male nurses (p=0.003). ICU nurses Had 3.5 times higher probability of optimal documentation than medical unit personal (OR=3.12 p<0.001). Nurses with over three years of experience and MSN degree performed much better (p<0.001). A regression research found that experience (β=4.12, p<0.001) and ICU posting (β=3.55, p=0.001 are significant predictors of documentation quality. Conclusion: These findings provide practical insights for healthcare set up seeking to improve nurse’s documentation habits in an electronic health records. To maximize the benefits of EHRs, customized intervention such as unit specific training, usability enhancement and gender sensitive measure are necessary.