Enfermería Clínica 31 (2021) S205---S209

www.elsevier.es/enfermeriaclinica

A systematic review of the implementation of

electronic nursing documentation toward patient
safety夽
I. Wayan Gede Saraswasta a,b , Rr. Tutik Sri Hariyati a,∗

a
Faculty of Nursing Universitas Indonesia, Depok, West Java, Indonesia
b
Klinik Utama Vidyan Medika, Gianyar, Bali, Indonesia

Received 15 September 2020; accepted 21 September 2020

KEYWORDS Abstract We find out the implementation of electronic nursing documentation toward patient
Electronic nursing safety. A systematic review of 15 articles were using PRISMA from five online database: Science
documentation; Direct, ProQuest, Scopus, Wiley Online, and Emerald Insight. The keywords used are ‘‘nursing
EHR; documentation,’’ ‘‘electronic health record,’’ and ‘‘patient safety). The implementation of
Patient safety EHR has an effect on patient safety i.e. improving identify patients correctly, improve effective
communication, improve the safety of high-alert medications, ensuring the correct location of
surgery, and reducing the risk of infection. In addition, it also reduces the risk of patient injury
due to falls by helping with falling risk screening process. Optimizing the implementation of
electronic nursing documentation affects the quality of nursing documentation and patient
safety. The result of this study may impact nursing managers while improving integrated EHR
with nursing documentation.
© 2020 Elsevier España, S.L.U. All rights reserved.

Introduction documentation has become a problem throughout the world,

The quality of nursing documentation shows the qual-
ity of nursing care.1 However, the quality of nursing
夽 Peer-review under responsibility of the scientific committee of
the 4th International Conference for Global Health (ICGH) in con-
junction with the 7th Asian International Conference in Humanized
Health Care (AIC-HHC). Full-text and the content of it is under
responsibility of authors of the article.
∗ Corresponding author.
E-mail address: tutik@ui.ac.id (Rr.T.S. Hariyati).
with an increasing number of patients. The implementation
of nursing documentation with good criteria was only 47.4%.2
The absence of documentation that shows the objective and
subjective results of nurse interactions with patients causes
discontinuity of patient care. Advances in information tech-
nology in the health industry encourage the implementation
of electronic nursing documentation systems in some health-
care organizations to improve the quality of documentation.
The implementation of electronic nursing documentation
could improve the quality and efficiency of providing health-
care services.1,3 Based on Jung’s study that 84% of health
facilities have used EHR in the US, while in Korea, 50.2%

https://doi.org/10.1016/j.enfcli.2020.12.023
1130-8621/© 2020 Elsevier España, S.L.U. All rights reserved.
 I.W.G. Saraswasta and Rr.T.S. Hariyati
of hospitals have used the EHR system.4 Nursing docu-
mentation in most hospitals in Indonesia is far from the
ideal standard. Nurses only meet 50---80% of the total doc-
umentation mandated by the Ministry of Health, which
indicates the low quality of nursing care. The majority
of paper nursing documentation in Indonesia causes low-
quality documentation. The implementation of electronic
nursing documentation (SIMPRO) could improve the quality
of nursing documentation.3
A study conducted by Charalambous and Goldberg
explained that 76% of nurses believed that electronic-based
documentation would improve patient safety.5 Increasing
the impact of EHR implementation on services provided has
encouraged many studies on EHR. However, few studies do
not discuss in detail the effects of implementing electronic
nursing documentation on patient safety. The purpose of
this study was to find out the implementation of electronic
nursing documentation toward patient safety.
Methods
This research method is a systematic review of 15 articles
using Preferred Reporting Items for Systematic Review and
Meta-Analysis (PRISMA).
1) Eligibility criteria: The inclusion criteria of this study
are published journal articles from 2015 to 2019. The
downloaded articles were researched from various coun-
tries. Meanwhile, the exclusion criteria from this study
is only one article would be selected if the same articles
published at some different online journal databases.
2) Search strategy: The keywords used to search for arti-
cles are ‘‘nursing documentation,’’ ‘‘electronic health
record,’’ and ‘‘patient safety.
3) Study selection: The identification of online journal
databases was based on sources from Science Direct, Pro-
Quest, Scopus, Wiley Online, and Emerald Insight. After
deleting duplicated articles, relevant articles were col-
lected. The review was carried out by filtering the title,
abstract text, and full text by conformity and similarity
to the contents of the journal or article. Then, data was
identified by describing the process of the PRISMA flow
diagram, as seen in Fig. 1.
4) Synthesis of results: Results from literature studies
illustrates and explain the implementation of electronic-
based nursing care documentation regarding patient
safety.
Results
Fifteen articles were included in the final review. This study
explains the implementation of EHR toward patient safety
goals. Electronic nursing documentation was developed to
assist nurses in providing high-quality healthcare services to
patients by prioritizing patient safety (Table 1).
Identify patients correctly
There are many opportunities for misidentification in health-
care services, ranging from patient registration to the
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provision of healthcare services. When providing services to
patients, nurses use various ways to identify patients, such
as bracelets, signs on headrests, stickers on clothing, and
identity badges.6 The implementation of electronic nursing
documentation helps nurses in identifying patients because
the available data has been integrated when the patient is
admitted to the hospital. The results of a study conducted
by Curtis et al. explain that the data available in the EHR
offers an important opportunity to identify a large number
of patients with serious illnesses.7 In addition, most clinical
decisions are taken from information in the patient’s medi-
cal record, which describes the patient’s current and past
conditions.
Improve effective communication
Communication in healthcare is very important but often
not properly documented. According to a study conducted
by Hou et al. with a respondent level of 72%, using an
electronic system with an ISBAR design could improve the
effectiveness of nurse communication and increase benefits
during patient hand-off.8 Moreover, the introduction of good
electronic nursing documentation could be useful in increas-
ing the interaction of healthcare workers with patients.3 In
addition, according to Thate, the development of a better
EHR supports inter-professional communication and team-
based care.9
Increasing the safety of drugs, especially ‘high
alert’ medications
Nurses must have pharmacological knowledge, competence
in calculating doses, skill in drug administration, and the
ability to assess the effectiveness of the treatment given.10
It encourages nurses to look for alternatives to help them
carry out their duties. In this way, the use of EHR helps
nurses provide efficient services to patients. Studies con-
ducted at Brigham and Women’s Hospital explained that the
adoption of EHR saved ten million dollars in ten years due
to the implementation of guidelines for the prevention of
medication errors.11
Ensure the correct location of surgery, the correct
procedure, and the correct surgery for the patient
One of the factors that influence the quality of service in the
operating room is documentation of every action taken. The
adoption of EHR has a large impact on the use of operating
rooms, which affects the overall profitability of hospitals.12
A study conducted by Robinson et al. showed that operating
records in EHR have increased accuracy, completeness, and
availability of medical records.13
Reducing the risk of infection related
to healthcare services
The implementation of EHR causes the nurse to document
the actions taken after leaving the patient’s room. According
to a study conducted by Yang, Bass, Bowles, and Sock-
olow, this could prevent infection.14 EHR implementation
 Enfermería Clínica 31 (2021) S205---S209
Figure 1 The process of selecting a literature study adapted from PRISMA (2015).
Table 1 Implementation of electronic nursing care documentation to patient safety goals.
No Category Reference
6,7,18
1 Identify patients correctly
3,8,9
2 Improve effective communication
10,11,19
3 Increasing the safety of High Alert
medications
12,13
4 Ensure the correct location of
surgery, correct procedure, correct
surgery for the patient
14---16
5 Reducing the risk of infection related
to health services
17
6 Reducing the risk of patient injury
due to falls
is proven to be feasible in a variety of conditions, although
most studies of its effects are sourced from America. EHR
implementation helps monitor healthcare related infections
(HCAI) by providing demographic, clinical, and epidemio-
logical information collected on a case-by-case basis.15 EHR
mining data is accurate for identifying routes of transmis-
sion among patients that are part of an outbreak. Based on
a study conducted by Sundermann et al., the implementa-
tion of EHR data mining in real time could prevent 66%-78%
of infection.16
Reducing the risk of patient injury due to falls
The availability of information potentially related to
patients falling allows a comprehensive investigation of the
trigger factors for the fall of the patient. The implementa-
tion of EHR could help the risk screening process. A study
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Important findings
Integration of data available in EHR could
help nurses identify patients.
72% of the implementation of electronic
systems could increase the effectiveness of
nurse communication.
EHR could reduce 50% of drug side effects
and save ten million dollars in ten years.
EHR has the potential to improve hospital
workflows, but in applying the EHR in the
operating room must be careful.
EHR mining data in real time could prevent
66%-78% chance of infection.
Electronic-based nursing documentation
could help the fall risk screening process.
conducted by Baus et al. explained that applying a model
using available data in EHR could identify risk factors for
falling patients.17
Discussion
Electronic nursing documentation has the potential to
improving patient safety. Identifying patients correctly
is first of patient safety goals. Patient identification is
very important because it is closely related to the pro-
cedure that would be provided to the patient.6 Based
on research conducted by Dwisatyadini, Hariyati, and
Afifah, the implementation of electronic nursing documen-
tation (SIMPRO) could improve the completeness of nursing
documentation.18 Without EHR, an average documentation
completeness before the implementation of SIMPRO is 1.87,
yet after SIMPRO, it increases to 3.61. Thus, according to
 I.W.G. Saraswasta and Rr.T.S. Hariyati
Curtis et al., data available in electronic nursing documen-
tation could be used to help identify patients correctly.7
Second, ineffective communication was one of the main fac-
tors affecting patient safety in the US from 2012 to 2014.8
According to research conducted by Dwisatyadini, Hariy-
ati, and Afifah, the implementation of SIMPRO helps nurses
make it easier to make decisions on nursing care and doc-
umentation plans.18 Additionally, it may also increase the
effectiveness of communication and support communication
between professionals and team-based care.8,9
Third, structured data from an EHR makes it possible to
identify potential drug interactions or allergies. According
to Han et al. and Mills, the implementation of EHR helps
nurses to provide efficient services to patients, especially
to improve the safety of alerted medicines (p < 0.001).11,19
It could also save money due to the implementation of
preventive guidelines against errors in the administration
of drugs.19 Fourth, the implementation of EHR has a large
impact on the use of operating rooms, which affects over-
all hospital profitability.12 In addition, based on a review of
2890 journal articles on the implementation of EHR, it may
also improve accuracy, completeness, and the availability of
medical records.13
Fifth, nurses have an important role in preventing
infection in hospitals. According to Phuong Quan et al.,
electronic nursing documentation that is integrated with
EHR helps the effectiveness of monitoring HCAI by 99.8%.15
In addition, research conducted by Setyaningrum, Hariy-
ati, and Novieastari explained that there was an increase
in nurse satisfaction as users of the HAIs surveillance sys-
tem before and after the intervention.20 It shows that
the computer-based HCAI’s supervision system influences
the completeness of documents and nurse satisfaction.20
Sixth, falling could cause physical injury and psychologi-
cal problems, including a loss of self-confidence and fear of
relapse, length of stay in the hospital, and financial burden.4
Electronic nursing documentation could help the fall risk
screening process so that it could quickly identify patients at
risk of falling. Hospital management plays a role in creating
strategies to improve patient safety in this case, to optimize
the implementation of EHR.
Conclusion
Electronic nursing documentation is an alternative strategy
to reduce the workload of nurses in making nursing care
documentation. The implementation of electronic nursing
documentation affects improving patient safety. It could
improve the quality of nursing care and improve patient
satisfaction with the nursing care provided. The result of
this study may increase understanding regarding electronic
nursing documentation implementation and impact on nurs-
ing managers while improving integrated EHR with nursing
documentation.
Conflict of interest
The authors declare no conflict of interest.
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Acknowledgements
This work is supported by Hibah PITTA B 2019
funded by DRPM Universitas Indonesia No. NKB-
0498/UN2.R3.1/HKP.05.00/2019.
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