CLINICAL SCHOLARSHIP

Electronic Nursing Documentation as a Strategy to Improve

Quality of Patient Care
Tiffany F. Kelley, MS, MBA, RN1 , Debra H. Brandon, PhD, RN, CCNS, FAAN2 ,
& Sharron L. Docherty, PhD, CPNP (AC-PC)3
1 Gamma Epsilon, Doctoral Candidate, Duke University School of Nursing, Durham, NC
2 Beta Epsilon & Alpha Alpha, Associate Professor, Duke University School of Nursing, Department of Pediatrics, Durham, NC
3 Iota Omicron, Associate Professor, Duke University School of Nursing, Durham, NC

Key words
Administration, informatics, information
technology, nursing practice, quality
improvement
Correspondence
Tiffany F. Kelley, Duke University School of
Nursing, Box 3322, 307 Trent Drive,
Room 3080, Durham, NC, 27710. E-mail:
tiffany.kelley@duke.edu
Accepted February 22, 2011
doi: 10.1111/j.1547-5069.2011.01397.x

Abstract
Purpose: Electronic health records are expected to improve the quality of care
provided to hospitalized patients. For nurses, use of electronic documentation
sources becomes highly relevant because this is where they obtain the majority
of necessary patient information.
Methods: An integrative review of the literature examined the relationship
between electronic nursing documentation and the quality of care provided to
hospitalized patients. Donabedians quality framework was used to organize
empirical literature for review.
Results: To date, the use of electronic nursing documentation to improve patient outcomes remains unclear.
Conclusions and Implications: Future research should investigate the dayto-day interactions between nurses and electronic nursing documentation for
the provision of quality care to hospitalized patients.
Clinical Relevance: The majority of U.S. hospital care units currently use
paper-based nursing documentation to exchange patient information for quality care. However, by 2014, all U.S. hospitals are expected to use electronic
nursing documentation on patient care units, with the anticipated benefit of
improved quality. However, the extent to which electronic nursing documentation improves the quality of care to hospitalized patients remains unknown,
in part due to the lack of effective comparisons with paper-based nursing documentation.

In Crossing the Quality Chasm, the Institute of Medicine

(2001) strongly recommended the use of electronic solutions to improve the quality of care provided to hospitalized patients. More recently, as part of the American Recovery and Reinvestment Act (ARRA) of 2009, hospitals
across the United States are expected to become meaningful users of electronic health records by 2014 (U.S.
Department of Health and Human Services [U.S. DHHS],
2010). Approximately 64% of patient care units currently
use paper-based nursing documentation and must convert to electronic nursing documentation in the next few
years or face financial penalties (Jha et al., 2009; U.S.
DHHS, 2010). While the impact of this national mandate crosses disciplinary lines, nurses, who collect the
majority of patient information (Chu, 1993) and are the
154

largest group of patient care providers (Aiken, Sochalski,

& Lake, 1997), may bear the greatest impact of this practice change. The purpose of this integrative literature review was to investigate the use of electronic nursing documentation on the quality of care delivered to patients in
hospital settings.

Nurses and Documentation

Documentation of patient care is a fundamental, yet
critical, skill used by nurses to communicate the current health status of the patients individual needs and
responses to care (Bjorvell, Wredling, & Thorell-Ekstrand,
2003). Nurses utilize their clinical expertise, prior knowledge, and critical thinking skills (Alfaro-LeFevre, 2009) to
Journal of Nursing Scholarship, 2011; 43:2, 154162.

C 2011 Sigma Theta Tau International

Electronic Nursing Documentation in Hospitals

Kelley et al.

continuously assess, plan, intervene, and evaluate their

patients. Nursing documentation supports nurses in their
ability to continuously reflect and critically think about
their patients in order to develop an individual plan of
care that will optimize health outcomes (Ammenwerth,
Mansmann, Iller, & Eichstadter, 2003; Bjorvell et al.,
2003). Yet, as integral as documentation is to the nursing
care process, little systematic evidence exists that examines the impact of nursing documentation on the provision of safe, quality care to hospitalized patients (Tapp,
1990).
Prior to the digital age, nurses used paper-based forms,
including narrative notes and flow sheets, to exchange
pertinent patient information (Bjorvell et al., 2003; Tapp,
1990). However, hospitals across the United States are
expected to meet the meaningful use criteria with electronic health records, including electronic nursing documentation, by 2014 in order to receive financial incentive payments (U.S. DHHS, 2010). Thus, the majority of
U.S. hospitals must convert from paper to electronic nursing documentation sources in a short time frame (Jha
et al., 2009; U.S. DHHS, 2010). However, the conversion
is more than a mere replication of paper forms in an electronic format (Ball, Hannah, Newbold, & Douglas, 2000).
Similar to paper-based documents, electronic systems
contain flow sheets to gather information about an individual patients needs and plan of care. However, electronic nursing documentation introduces new features,
such as copy and paste (Siegler & Adelman, 2009), electronic interfaces (Kroth, Belsito, Overage, & McDonald,
2001), and structured drop-down menus (Kossman &
Scheidenhelm, 2008), not found in paper documents.
These features may alter how nurses use documentation to record, make decisions, and communicate with
other caregivers and therefore may impact care quality
(Nemeth, Nunnally, OConnor, & Cook, 2006).
With these features, a nurse can copy and paste previously charted data for the current assessment through a
few clicks of the mouse (Siegler & Adelman, 2009). While
a nurse could also copy an assessment written on paper, the time effort would be much greater and the nurse
would be more likely to appropriately edit the data because he or she controls the pen while transcribing. Electronic nursing documentation systems can electronically
transfer vital sign data from cardiorespiratory monitors
into flow sheets through interfaces without requiring a
nurse to transcribe this information onto a piece of paper (Kroth et al., 2001). Finally, when documenting assessments, nurses can use drop-down menus that have
predetermined choices built into the electronic system as
free form writing by the nurse is no longer seen as an advantageous method of documenting patient information
(Robles, 2009). While drop-down menus provide a stan-

dardized language that can facilitate tracking adherence

to clinical standards, the documented information may
be of limited clinical use due to the structured nature of
the system.
While these features of electronic nursing documentation are seen as time savers for nurses (Robles, 2009),
they may alter the processes by which nurses assess and
critically think about the patient status and care. The use
of interfaces and copy and paste features has the potential to include data elements that are not valid representations of the patients current condition. As a result, nurses
are now forced to diligently assess not only the patient
but also the data found on multiple screens to ensure that
the values are accurate reflections of the patients current health status. Given that electronic documentation
has both strengths and potential for weaknesses that may
lead to errors, investigating the existing literature on the
use of electronic nursing documentation for the provision
of quality care to hospitalized patients is imperative. Literature was organized according to Donabedians (1980)
framework of quality to aid in evaluating the scope of
knowledge on the topic.

Quality
The Institute of Medicine (2001) defined quality as the
extent to which healthcare services provided to patients
improve their overall health status. The definition was
based on Donabedians (1980) conceptual framework of
quality. Donabedian described quality according to three
constructs: structure, process, and outcomes (Figure).
We used Donabedians model of quality to organize results of the literature review as most nurses are familiar with the framework. Although Donabedian discussed
structure, process, and outcomes in that order, it is also
legitimate to think first about outcomes (what one wants
to achieve) and work backward to think about process
and then structures needed to support the outcomes. In
this article, we discuss outcomes first, followed by process
and structure.
Much of the national attention around the use of
electronic solutions assumes that there is a potential
for improved patient health outcomes. Outcomes in
Donabedians (1980) framework refer to reaching the optimal health status of the individual patient or groups
of patients that received care. However, Donabedian
asserted that high-quality outcomes depend on highquality processes and structures. Process in Donabedians
framework is about what actually is done in providing
care, and structure is about the setting of care, including
the staff, facilities, and equipment. Thus, process concerns
what is done by nurses to provide care, such as using a
structural component like electronic documentation. In
155

Electronic Nursing Documentation in Hospitals

Structure

Kelley et al.

Process

Outcomes

Nurses
Nurses

electronic
documentation

(interaction for
patient care delivery)
electronic
documentation

Patient
health status
at discharge
or transfer
from hospital

Figure. Donabedians (1980) quality framework.

this review, process refers to the day-to-day interactions

between the nurses and the electronic nursing documentation system. Structural aspects relevant to nurses use
of electronic documentation include nurse characteristics
within the hospital and electronic nursing documentation characteristics. The purpose of this integrative literature review was to investigate the assertion that electronic nursing documentation has improved the quality
of care provided to hospitalized patients.

Methods
A database search of PubMed and the Cumulative Index for Nursing and Allied Health Literature (CINAHL),
was conducted using the Medical Subject Headings
(MeSH) terms Medical Record Systems, Computerized,
Hospital Information Systems, Documentation, Communication, Nurses and Nursing and CINAHL key words
Documentation, Computerized Patient Record, Attitudes,
and Nurses. PubMed was searched first by combining
MeSH terms. Eighteen research articles were selected for
review from PubMed. Five additional articles not found in
PubMed were retrieved from CINAHL. CINAHL retrieved
11 duplicates from the 18 retrieved in PubMed. Two articles were retrieved from reference lists on the topic of
attitudes toward computerization. One article cited is an
unpublished manuscript. Only articles that studied the
use of electronic nursing documentation in hospital settings were selected for review. The search strategy resulted in 24 studies for review published over the past 30
years. Each article was reviewed and organized according
to which construct (e.g., structure, process, outcome) the
research question addressed within the study. The topic
areas presented in the results were derived from the literature (Table S1, available at Wiley Online Library).

Results
Outcomes
Outcomes in Donabedians (1980) model refer to the
health status of patients. Yet, nursing leadership will
also assess nurses satisfaction as an indicator of quality
156

(Kossman & Scheidenhelm, 2008). Thus far, the existing literature is greatly limited in the empirical evaluation
of health outcomes as a result of electronic nursing documentation. While limited, the existing literature does
discuss nurses satisfaction with electronic nursing documentation. The absence of patient-related outcomes is
indicative of what is known and not yet known in relation to the use of electronic nursing documentation for
the quality of care to hospitalized patients.

Nurse Satisfaction With Electronic Nursing

Documentation
The extent of nurses satisfaction with electronic nursing documentation was the primary topic area of investigation on quality outcomes to date. Much of the research in this area was conducted through interviews
or questionnaires to understand the nurses experience
(Darbyshire, 2004; Kossman & Scheidenhelm, 2008;
Likourezos et al., 2004; Moody, Slocumb, Berg, &
Jackson, 2004). Nurse perceptions about using electronic
documentation included frustrations about providing individualized patient care (Darbyshire, 2004; Likourezos
et al., 2004), difficulty in finding an available computer
(Timmons, 2003), recalling ones password, and the slow
speed of the computer (Darbyshire, 2004). These findings (Darbyshire, 2004) suggested that nurses focused on
the characteristics of the electronic documentation system. Despite these challenges, one study (Moody et al.,
2004) found that 81% of the nurses (n = 100) believed
that electronic documentation helped with the provision
of patient care, with 75% of the nurses feeling confident
that documentation improved as a result of the electronic
format. Unfortunately, this study did not ask the nurses
how the electronic documentation helped nurses deliver
patient care nor did it evaluate patient outcomes (Moody
et al., 2004). Nurses in another study reported being able
to complete their work quicker with electronic documentation than paper-based documentation (Likourezos
et al., 2004). Future research may ask nurses how the
electronic documentation facilitated the delivery of safe
care to gain insight into variables that could be extracted

Kelley et al.

from the electronic nursing documentation for evaluating

patient health outcomes.

Process
Effect of electronic nursing documentation on
time. Health outcomes in Donabedians (1980) framework are directly influenced by the processes of care
delivery. In this review, the processes of interest are
the day-to-day interactions of nurses with the electronic
nursing documentation system for influencing the quality
of health outcomes to hospitalized patients. One processrelated issue is the time required to use electronic instead
of paper-based nursing documentation. Nurses were concerned that use of electronic nursing documentation
would reduce the time available for direct patient care
by increasing the time spent documenting through an
electronic rather than paper format (Asaro & Boxerman,
2008). Nurses concerns were supported in one study of
nurses (n = 46) who spent a median of 50% of their overall shift (range 25% to 98%) using the electronic documentation system (Kossman & Scheidenhelm, 2008).
However, the findings are limited due to the self-reported
data on time spent documenting rather than more rigorous techniques such as direct observation or time motion studies. Further, no reference was provided on the
amount of time spent documenting on paper for comparison about whether time available for patients is better or
worse with electronic documentation.
Other studies of nurses documentation time had
conflicting results (Asaro & Boxerman, 2008; Hakes &
Whittington, 2008; Pabst, Scherubel, & Minnick, 1996;
Saarinen & Aho, 2005; Smith, Smith, Krugman, &
Oman, 2005). Nursing documentation time significantly
increased over paper documentation by 14 min during
a shift (Saarinen & Aho, 2005), while a second study
found that documentation time decreased by 20 min per
shift (Pabst et al., 1996). Three other studies detected no
statistically significant change in documentation time before and after electronic nursing documentation (Asaro
& Boxerman, 2008; Hakes & Whittington, 2008; Smith
et al., 2005). Documentation time was found to significantly differ between units (Saarinen & Aho, 2005),
indicating that patient care units may have structural
or process-related differences that influence the time
needed to document. Nurses also spent more time documenting on the day shift (19.17%) than the night shift
(12.41%; Korst, Eusebio-Angels, Chamorro, Avadin, &
Gregory, 2003). These findings suggest that nurses may
require varying amounts of time to document the provision of patient care depending on the setting of care and
the patients condition. More time required to document
may be acceptable if the additional time has a positive

Electronic Nursing Documentation in Hospitals

effect on the patients overall health status. Future studies of documentation time should investigate why nurses
spend more time documenting one type of data than another and evaluate the potential benefits or consequences
on the patients health status.
Provision of nursing care. Understanding how
nurses use electronic nursing documentation for the provision of care to hospitalized patients is essential. Findings
from a recent study of nurses (n = 46) found through
interviews and observations that nurses relied less on
their own memory when using electronic documentation compared with paper documentation (Kossman &
Scheidenhelm, 2008). Nurses felt the electronic documentation aided their memory by placing care options
in a predetermined drop-down menu that did not require the nurse to remember what data elements to chart.
A similar result emerged from a study that investigated
nurses perceptions of electronic care plans (Lee, 2006).
Nurses (n = 20) found electronic care plans assisted them
in remembering aspects of patient problems (Lee, 2006).
While predetermined drop-down menus were beneficial to some nurses (Asaro & Boxerman, 2008), others
felt it had the potential to make it easy for nurses to
not think about the nursing care process (Kossman &
Scheidenhelm, 2008). Less reliance on a nurses memory may transfer more reliance to the electronic nursing
documentation. The impact of the decreased emphasis on
ones memory of patient information on nurses care giving warrants further investigation.
Other features were also perceived to affect how nurses
provided care. The copy-and-paste feature allows nurses
to copy previously documented data and paste it into
the current time frame (Siegler & Adelman, 2009). While
more efficient than retyping the data, nurses mentioned
in interviews this feature runs the risk of pasting data
that may no longer be applicable or accurate about the
patient. Thus, the nurse must stop and think about each
documented data element (Kelley & Brandon, 2010). Additionally, the structured format of the electronic nursing documentation was described as having the potential
to limit the full description of the patients health status (Kelley & Brandon, 2010; Lee, 2006). These studies
(Kelley & Brandon, 2010; Kossman & Scheidenhelm,
2008; Lee, 2006) did not provide clear answers on the
impact of these features and suggest the need for additional investigation to understand nurses interactions
with electronic nursing documentation, the effects on
their critical thinking, and the impact on the delivery of
safe, quality patient care.
Nurses also found that the electronic nursing documentation did not completely meet their information
needs in their day-to-day practice. For example, nurses
expressed difficulty in retrieving previously entered infor157

Electronic Nursing Documentation in Hospitals

mation (Darbyshire, 2004). Nurses also felt that the organization of the nursing documentation system was not an
accurate representation of nursing practice (Darbyshire,
2004). In three studies, nurses felt that only limited
information could be communicated through the electronic nursing documentation (Darbyshire, 2004; Kelley
& Brandon, 2010; Korst et al., 2003). Nurses in two of
these studies found the electronic nursing documentation
least useful in communicating the personal aspects of
the patient (Kelley & Brandon, 2010; Korst et al., 2003).
Future research needs to focus on these information gaps
by inquiring directly with nurses about why certain types
of information are not located within the documentation.
Nursing communication. Communication with
other nurses and providers is a major part of delivering patient care (Morrison, Jones, Blackwell & Vuylsteke,
2008) and a high-risk time for medical errors (Fortescue
et al., 2003). While known that nurses use a combination
of verbal and written sources to communicate pertinent
patient information (Coiera & Tombs, 1998; CorcoranPerry & Graves, 1990; Kelley & Brandon, 2010), little
is known as to what types of information nurses verbally communicate rather than document in the paperbased nursing documentation. One study investigating communication patterns revealed decreased verbal
communication between nurses and providers following
the implementation of electronic nursing documentation
(Morrison et al., 2008). Another study found that nurses
were often unable to document necessary patient information because the predetermined drop-down menu
could not capture what the nurse wanted to portray
(Kelley & Brandon, 2010). With paper documentation,
nurses were not faced with this issue because they were
at liberty to write the pertinent information within the
confined space of the flow sheet (Robles, 2009). These
studies suggest that converting from paper to electronic
documentation sources has implications for the communication of patient information across the healthcare
team (Morrison et al., 2008). Yet, communication patterns remain an underdeveloped area in nursing research
(Coiera & Tombs, 1998; Fortescue et al., 2003; Morrison
et al., 2008). Understanding the communication patterns
on paper before converting to electronic documentation
would be ideal in order to address potential obstacles for
efficient information exchange following implementation
of electronic nursing documentation.

Structure
Attitudes toward electronic nursing documentation. Finally, the structure of the hospital was directly related to the processes of care delivery and subsequently the patients health outcomes (Donabedian,
158

Kelley et al.

1980). Nurses attitudes toward electronic nursing documentation have been studied extensively over the past
20 years with the thought that individual attitudes may
affect the nurses use of electronic nursing documentation and impact patient care delivery (Alfaro-LeFevre,
2009; Alquraini, Alhashem, Shah, & Chowdhury, 2007;
Ammenwerth et al., 2003; Bongartz, 1988; Brodt &
Stronge, 1986; Getty, Ryan, & Ekins, 1999; McConnell,
OShea, & Kirchhoff, 1989; Moody et al., 2004, Murphy,
Maynard, & Morgan, 1994; Scarpa, Smeltzer, &
Jasion, 1992; Schwirian, Malone, Stone, Nunley, &
Francisco, 1989). Thus, scholars investigated the relationships between several nurse characteristics and the
associated attitudes toward electronic documentation.
The characteristics included age, gender, nationality, education level, years of nursing experience, and prior
use of computers (Alquraini et al., 2007; Ammenwerth
et al., 2003; Brodt & Stronge, 1986; Moody et al., 2004;
Murphy et al., 1994; Scarpa et al., 1992; Schwirian et al.,
1989).
Research findings related to nurses age were inconclusive. Several studies (Brodt & Stronge, 1986; McConnell
et al., 1989; Scarpa et al., 1992) found no statistical relationship between age and nurses attitudes, while another (Moody et al., 2004) found that younger nurses
attitudes were more favorable than older nurses toward
computerization. Only one study, conducted in Kuwait,
investigated nationality. Non-Kuwaiti nurses had significantly higher scores, indicating more favorable attitudes
toward computerization than Kuwaiti nurses (Alquraini
et al., 2007). In the same study, female nurses reported
more favorable attitudes toward computerization than
male nurses. Yet, gender was not significantly related to
attitudes in another study that used the same instrument
(Murphy et al., 1994). Unfortunately, gender and nationality were not investigated in other studies of nurses attitudes toward computerization (Bongartz, 1988; Brodt
& Stronge, 1986; McConnell et al., 1989; Moody et al.,
2004; Scarpa et al., 1992; Schwirian et al., 1989).
While two studies (Murphy et al., 1994; Scarpa et al.,
1992) did not find that a nurses education level predicted their attitudes about electronic documentation,
other studies (Alquraini et al., 2007; Brodt & Stronge,
1986) found that the higher the nurses education level,
the more favorable their attitudes. Nurses with over 20
years of experience had more favorable attitudes than
nurses with less than 10 years of experience (Brodt &
Stronge, 1986); however, this finding was not supported
in other studies (Moody et al., 2004; Scarpa et al., 1992).
Finally, prior computer use was the only variable with
consistent findings (Alquraini et al., 2007; Ammenwerth
et al., 2003; Moody et al., 2004; Scarpa et al., 1992).
All of these studies found that nurses with prior expe-

Electronic Nursing Documentation in Hospitals

Kelley et al.

rience with computers had more favorable attitudes toward electronic documentation.
While many of these studies took place over 20 years
ago, their findings remain important. Using Donabedians
(1980) framework there must be a strong understanding of the structural aspects, such as nurses characteristics and attitudes to understand workflow processes
that may impact health outcomes. These findings demonstrate that while there may be differences between the
nurses characteristics, prior use with computers was
the only variable consistently shown to have a significant relationship with more favorable attitudes toward
electronic documentation. Despite these inconclusive results, little has been done thus far to link attitudes about
computers to the quality of care provided using electronic
nursing documentation for hospitalized patients.
Functionality and usability of the system. Structural characteristics of electronic nursing documentation
studied included functionality and usability of a system
(Ball et al., 2000; Darbyshire, 2004). Cross-sectional survey responses from nurses (n = 100) demonstrated that
while 96% were confident in their abilities to use the
electronic documentation system, less than half (44%)
believed the documentation system met their needs
(Moody et al., 2004). The majority of nurses (54%) were
often documenting on paper and then transferring information to the electronic documentation system because
the electronic record was cumbersome to use at the bedside (Moody et al., 2004). The study did not specify which
nurses needs were not met through the electronic nursing documentation.
Despite these reported challenges with the usability of electronic nursing documentation in practice,
nurses in another study reported some functional benefits
(Kossman & Scheidenhelm, 2008). Nurses had increased
visibility and access to information about admitted patients and those patients expected to arrive from another unit within the hospital. Nurses perceived that the
drop-down menus with predefined documentation options increased the organization of entering data about
the patient through pick lists and sequential structured
entry of patient assessments (Kossman & Scheidenhelm,
2008). However, nurses in this study also described
some consequences of the electronic documentation
(Kossman & Scheidenhelm, 2008). Nurses perceived that
the functions in the electronic format may negatively
impact nurses ability to think critically about their patients due to features such as copy and paste, dropdown menus, and check boxes, not previously available
on paper. These findings are important to gain nurses
perspectives on the usability and functionality of electronic nursing documentation, but how these structural

aspects impact patient care and patient outcomes remains

unclear.

Limitations of Research to Date

There were several limitations within the research conducted thus far on the use of electronic nursing documentation for hospitalized patients. Many of the research studies used descriptive cross-sectional designs to
understand the variables that influence the experiences
of nurses when using electronic documentation in hospital settings. However, these study designs are limited in
the ability to determine causation between variables because data is collected at one time point (Polit & Beck,
2004). Several of the studies used different instruments
to measure nurses attitudes or perceptions of electronic
nursing documentation, which limits the comparison of
study findings. Finally, the empirical evidence to date is
limited in the evaluation of the process and outcomes
constructs of quality.

Discussion
From this integrative literature review, research gaps
remain across the three constructs of quality (structure,
process, outcomes; Donabedian, 1980), and whether
electronic nursing documentation improves the quality of
care provided to hospitalized patients remains unknown.
These studies provided extensive empirical evidence of
the attitudes of nurses about electronic documentation
as well as their perceptions of its use within the hospital
environment. While this knowledge provided a valuable
starting point, the impact of electronic nursing documentation on the quality of care delivered to hospitalized patients is not well understood.
Therefore, research is needed to understand the ways
in which nurses interact with nursing documentation on
paper to maximize the effective use of an electronic format. With the majority of the nations hospitals still documenting on paper (Jha et al., 2009), this task is not
only feasible but is imperative to the successful implementation of electronic nursing documentation for those
hospitals faced with this challenge over the next several years. Those hospitals that have already converted
would be able to identify areas for redesign and modification within their current electronic documentation
system. More specifically, work is needed to understand
the patterns of information use by nurses caring for hospitalized patients. To gain this knowledge, observational
research is needed to determine how electronic nursing
documentation supports and does not support the daily
exchange of patient information for the delivery of safe
nursing care.

159

Electronic Nursing Documentation in Hospitals

Understanding the types of information collected and

communicated through all sources would also contribute
to the development of nursing documentation standards
(American Nurses Association, 2008). One reason for
the lack of documentation standards may be the uncertainty around what information is being documented
for the purpose of providing patient care as compared
with information being documented for the purpose of
meeting regulatory requirements. Having documentation
standards based on the patient information needed to
provide safe high-quality care could aid in influencing the
design and optimizing the use of electronic nursing documentation systems. In practice, nurses need to be aware
of their interactions with electronic nursing documentation to provide patient care. Nursing leadership must be
aware of the limited knowledge about electronic nursing documentations contribution to patient care quality
(Mahler et al., 2007).

Conclusions
The national agenda (Jha et al., 2009; U.S. DHHS,
2010) assumes that the use of electronic sources, such as
nursing documentation, will greatly improve the quality
of care provided to hospitalized patients. The majority of
hospitals across the United States are expected to convert to electronic health records in the next few years
as a result of the ARRA of 2009 (U.S. DHHS, 2010).
However, the underlying assumption that the conversion
from paper to electronic nursing documentation will improve the health outcomes of patients has yet to be confirmed, as evidenced by this literature review. In fact, this
assumption may never be proven or disproven if action is
not taken to first gain an in-depth understanding of the
use of paper-based nursing documentation by nurses caring for hospitalized patients. The understanding of how
nurses use paper would allow for an effective comparison
for those using electronic documentation. Only then can
comparisons be made about similarities and differences in
its use as well as identify factors that may be reliable indicators to use as predictors of patient health outcomes.
These findings would be useful to all hospitals regardless
of the stage at which they have converted to a fully integrated electronic record.

Acknowledgments
We would like to thank and acknowledge our colleagues Ruth Anderson, PhD, RN, FAAN, Virginia Stone
Professor of Nursing, Kimberly Allen, MSN, RN, PhD
Candidate, and Ryan Shaw, MS, RN, PhD Candidate, at
Duke University School of Nursing, for their contributions in revising this manuscript for publication.
160

Kelley et al.

Clinical Resources
r Institute of Medicine: http://www.iom.edu/
r Office of National Coordinator for HIT: http://
healthit.hhs.gov/portal/server.pt/community/
healthit hhs gov home/1204

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Table 1. Literature Review of Electronic Nursing Documentation for the Quality of Care to Hospitalized Patients.
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