Date of Conferral

2017

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Deborah Lewis

Abstract

Electronic nursing documentation systems can facilitate complete, accurate, timely documentation practices, but without effective policies and procedures in place, a gap in practice exists and quality of care may be impacted. This systematic review of literature examined current evidence regarding electronic nursing documentation quality. General systems theory and the Donabedian model of health care quality provided the framework for the project. Electronic databases PubMed and the Cumulative Index of Nursing and Allied Health were searched for articles addressing electronic nursing documentation practices. The Cochrane systematic review methodology was used to analyze the articles. Articles were excluded if published before 2001 or not in the English language. The search revealed 860 articles of which 35 were included in the final review. Most studies were quasi-experimental involving multiple interventions such as clinical decision support (CDSS), education, and audit and feedback specific documentation foci. The most reported outcomes were an improvement in documentation completeness and correctness. A multifaceted intervention strategy consisting of CDSS, education, and audit and feedback can be used to improve electronic documentation completeness and correctness. Policies and procedures regarding documentation practice should support the intended outcomes. Electronic documentation systems can improve completeness, but care should be taken not to depend on the quantity of documentation alone. Further research may shed light on the importance of concordance or plausibility, and the truth of documentation and ultimately how that can impact social determinates of health and social change.

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