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ZENODO
Article . 2025
License: CC BY
Data sources: ZENODO
ZENODO
Article . 2025
License: CC BY
Data sources: Datacite
ZENODO
Article . 2025
License: CC BY
Data sources: Datacite
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Role of Electronic Health Records in Enhancing Nursing Documentation in Medical-Surgical Units

Authors: Naresh Chand Meena;

Role of Electronic Health Records in Enhancing Nursing Documentation in Medical-Surgical Units

Abstract

EHR (Electronic Health Records) have become a revolutionary force in contemporary healthcare, especially in relation to advancing the quality and efficiency of nursing documentation in medical-surgical units. This study, which focused on EHR systems to demonstrate documenting practices, found not only that accuracy, accessibility, and standardization of records of care provided to patients improved when documented in EHR, but also that by transitioning from paper-based documentation, EHR supports immediate entry of data, includes features to reduce documentation errors, and expedites communication among interdisciplinary team members in real-time. The EHR electronic document features of medical-surgical units also provide nurses with structures of templates, automated notifications, and other decision-support technologies, which foster more accurate assessment documentation, continuity of care, and adherence to clinical practice guidelines. EHR improves patient safety through improved medication administration records, redundancy of documentation recorded in the medical record, and adoption of health information technology breaking barriers to communication. Challenges to practice associated with EHR include perception of increased workload, training access, and usability flaws; however, EHR ultimately supports evidence-based practice and benefits patient outcomes of care overall. This abstract demonstrates that while EHR may change practices of documentation, nursing patients in medical-surgical units positively strengthens documentation practices and supports the subsequent quality, safety, and efficiency of care delivered in healthcare settings.

Keywords

Electronic health records, quality of care, patient safety, indicators, electronic nursing documentation

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selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
0
Average
Average
Average
Green