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Comprehensive review shows electronic nursing records improve patient care quality, indicating the need for standardized documentation in clinical practice.
Background: The evolution of nursing from a practice-oriented to a science-based discipline necessitates the integration of health information systems, particularly electronic nursing records, to enhance patient outcomes and streamline clinical workflows. The World Health Organization has recognized the importance of emerging technologies in healthcare management, emphasizing standardized documentation practices in nursing. Methods: This study employs a comprehensive literature review methodology to explore the role of nursing informatics in integrating health information systems into clinical practice. The analysis focuses on various nursing classification systems, the impact of electronic nursing records on documentation quality, and the correlation between digital records and patient care outcomes. Results: The findings indicate that the implementation of electronic nursing records significantly improves the quality of nursing documentation, enhances patient safety, and facilitates evidence-based practice. Furthermore, the study reveals that standardized nursing terminologies, such as NANDA, NOC, and NIC, are essential for effective communication among healthcare providers and contribute to better patient care coordination. However, challenges such as insufficient training and varying levels of technology adoption across countries persist. Conclusion: The integration of health information systems in nursing practice is crucial for optimizing patient care and improving health outcomes. Continued efforts to standardize nursing documentation and enhance digital literacy among healthcare professionals are necessary to fully harness the potential of electronic nursing records. Future research should focus on the long-term impacts of electronic nursing records on nursing practice and patient outcomes across diverse clinical settings.
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Alnaji et al. (2024) studied this question.
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