Quality of nursing documentation
Article 1 Summary
The Quality of nursing documentation: Paper‐based health records versus electronic‐based health records article focuses on nursing with a particular interest in electronic health records. Technological advances over the past years have necessitated the integration of IT in the health care sector. The assimilation aims at improving patient care outcome by incorporating a system that can store data more accurately than traditional manual records methods. Information concerning a patient’s illness, treatment, medication, prescription, discharge, admission to name a few are recorded in the EHR system. Retrieval of such information is more accessible, but as the article indicates it does not always equate to increased effectiveness and patient care quality (Akhu-Zaheya et al., 2017, p587) and has its drawbacks. To give better insight into the subject, research was carried out in two Jordanian hospitals, one with paper-based and the other electronic records. The sample included patients in two public hospitals and results from the hospital using EHRs indicated better patient outcomes than the one using paper-based records. The research method used involved a descriptive option, and the sample was taken from the medical and surgical wards from the two hospitals.
The results indicated that electronic health records use gave better results than a paper-based record. The former uses a typed format making it legible as opposed to the latter method that was handwritten reducing misinterpretation and misreading errors. Use of charts and other structures is also used in electronic systems but cannot be used in manual records meaning that EHRs promote various data structures. The EHR used though recording better results were, however, not without limitations as the interpretation of formats like charts may not be easy further complicating the data retrieval process. It means that there is a need to incorporate informatics in nursing studies (Akhu-Zaheya et al., 2017, p.588) to better equip these professionals with the skills needed to use technology seamlessly.
Article 2 Summary
The Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences article is based on research conducted on electronic health records. The article’s focus is on the terminologies used in electronic health records and whether the terms are deemed user friendly by nurses. The results indicated that half of the sample used nursing informatics terminologies (De Groot et al., 2019, p.2). The method used involved an internet-based questionnaire, and the sample included Dutch nurses, unlike the research in the previous article, which focused on patient records in two Jordanian hospitals. Survey questions were sent to nursing professionals in various health care settings such as hospitals and nursing homes with reminders sent frequently to ensure participation. The outcomes indicated that the terminologies used were related to the setting of the participants. Home care nurses used one type while hospital nurses applied another; thus, terminology use was based on the health care setting (De Groot et al., 2019, p.13).
Documenting nursing information is an essential component in the implementation and use of EHRs. Having standardized terminologies makes the process easier as margins of error are reduced. When such terms are not well articulated, nurses are more likely not to use them or misuse them. Standardizing terminology is vital as confusion and different understanding of terms to have more than one meaning is eliminated. The fact that only half of the sample used standardized terms is indicative of a need to make the software more user friendly in regards to standardized terminology (De Groot et al., 2019, p.17). If terminologies are not well understood then the input process is flawed from the beginning compromising the authenticity of the entire system. A considerable number of nurses felt that the system did not fully support nursing needs. The results indicating that half of the sample used nursing informatics terminologies (De Groot et al., 2019, p.21) is indicative of a need for standardized terminology that is easier to understand and use.
Experience Using CINAHL to Locate Articles
The Cumulative Index to Nursing and Allied Health Literature (CINHAL) is a database recommended for nursing-related information, making it a recommended website source for peer-reviewed journals (Wright et al., 2015, p.1). The experience using CINAHL is friendly and non-time consuming, which is vital to a student researching a particular subject. The website is straightforward to use, and location of the required nursing articles is fast. CINAHL has a collection of journal articles and has categories based on publication year. Locating current electronic health journals within the last five years only requires selecting the year category that is of interest. Some articles have a PDF format indication giving a reader the option of accessing an article that has a downloadable format.
The website has multiple journals in various subjects, and one only needs to type the topic, and various articles are generated for the reader. The entire process is swift and would recommend it to students for use when doing research papers. For assignments requiring academic resources as the references, the website is the go-to place as there are tons of articles. Accessible articles make the process fluid, time saving and reliable. However, the database only seems to have research papers; hence a reader interested in other types of papers may not find the article very useful. The main focus is on nursing, which means that other subjects of interest away from the health care domain may not be located on the website. For those interested in the journal reviewed nursing articles, CINHAL is an excellent site.
References
Akhu-Zaheya, L., Al-Maaitah, R., & Bany Hani, S. (2017). Quality of nursing documentation:
Paper-based health records versus electronic-based health records. Journal of Clinical Nursing, 27(3-4), e587-588. https://doi.org/10.1111/jocn.14097
De Groot, K., De Veer, A., Paans, W., & Francke, A. (2019). Use of electronic health records
and standardized terminologies: A nationwide survey of nursing staff experiences. International Journal of Nursing Studies, 104, 2-21. https://doi.org/10.1016/j.ijnurstu.2020.103523
Wright, K., Golder, S., & Lewis-Light, K. (2015). What value is the CINAHL database when
searching for systematic reviews of qualitative studies?. Systematic Reviews, 4(1), 1. https://doi.org/10.1186/s13643-015-0069-4