Nursing Documentation in the Electronic Age

Subject: Nursing
Pages: 2
Words: 584
Reading time:
3 min
Study level: College

Nursing Notes and other documentation procedures in healthcare are essential in care provision. Documentation facilitates maintaining the record of all services received by the patient and is critical for handing over duties within healthcare facilities (Kollerup et al., 2018). In the care delivery process, patients undergo several procedures, all of which should be documented. In the practice of nursing, something done and not documented is considered not done. Therefore, immediate and correct documentation is necessary to avoid missing out on minor details that may easily be forgotten.

To address the issues, first, it could be salient to understand the reasons for the delays. In current practice, most nurses have adopted a trend of documenting after they have delivered care. Since electronic documentation is a new initiative, most of them may not be familiar with the operations of computers. To aid in such a situation, it could be ideal for organizing training sessions for the staff members as the in-charge (McCarthy et al., 2019). On off-duty days or after the nurses have completed their shifts, they can learn how to operate the computers.

Providing the team members with the procedure manuals of the computers will also help them understand the machines. The guidelines will enable them to document and do it immediately instead of waiting until aftercare to ask for help in keying in the data (McCarthy et al., 2019). Hiring nurses’ assistants will be of the essence in reducing the nurses’ workload and will allow for the provision of care and documentation promptly within the shift.

Electric documentation has played a significant role in promoting care delivery. Therefore, it has impacted the patient’s health and life positively. Electronic documentation has aided in eliminating paperwork that was both hectic and prone to errors. Unlike the traditional method of documentation, the computerized system allows for accurate, timely, and complete information about the patient. In ensuring quality in healthcare, immediate access to patient information is vital to minimize errors.

With accurate medical and nursing diagnosing the quality of care provided is improved. Most errors, such as medication errors, occur due to the failure of the nurse to either identify the right patient or the right drug. With computers in each patient room, it is easy for the care provider to counter-check the right patient and medication before administering. Some of the electronic gadgets installed in the facilities have stored information that can be used in care delivery, especially when diagnosing (Mesko, 2017).

Keyed-in data is more legible therefore minimizing errors of reading wrong information due to poor handwriting. Patient information should be private and only accessible by the nurse, clinical staff, and the patient. When documenting on paper and files kept by the bedside, unauthorized people would access them and compromise privacy, however with computerization, to access the details, one will require a password that is only available for the authorized members.

Advanced technology plays a significant role in facilitating the modernization of healthcare. Technology aids in the improvement of the machines used in care, making them more efficient and accurate. The new tools available due to technological advancements limit medical errors such as misidentification of patients. Patient education has been eased due to technology that has enabled the development of devices such as medical apps (Mesko, 2017). Improvement in technology has also modernized training and education in nursing schools. Medical research aimed at improving the standards of care has been launched due to technology, and the findings are being used to provide adequate care to patients.


Kollerup, M., Curtis, T., & Laursen, B. S. (2018). Improving visiting nurses’ post-hospital medication management: A participatory approach. Journal of Integrated Care. 26(1), 65-76. Web.

McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett‐Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3), 491-501. Web.

Mesko, B. (2017). The role of artificial intelligence in precision medicine. Personalized Medicine in Drug Development and Clinical Practice. 2(5), 239-241. Web.