Contributions of the electronic record for nursing assistance from the view of the quality audit
DOI:
https://doi.org/10.33448/rsd-v11i14.36001Keywords:
Electronic health records; Nursing audit; Patient care planning.Abstract
Objective: to analyze the contribution of the electronic medical record to nursing care in the face of the quality audit. Methodology: integrative literature review carried out in May and June 2022, in the SciELO, Scopus, PudMed, Science Direct, BDENF and BVS databases. Results: the initial search resulted in 500 scientific articles, which titles and abstracts were read, and only 86 were selected for full reading. Of these, 17 articles were selected for answering the research question and three were excluded due to duplicity, resulting in a final sample of 14 articles. Several benefits were observed in the use of electronic medical records for nursing care within the quality audit, highlighting the increase in confidence in sharing the results and recommending solutions, the improvement in the standardization of information and the possibility of performing a quick review. in audits. It was also possible to verify that the use of electronic medical records was associated with a reduction in the risk of medication errors, support for clinical decisions and optimization of work flows and institutional organization. Final considerations: Computerization of health records has a significant impact on improving the safety, efficiency and quality of care, while protecting the privacy and personal rights of the patient. The use of electronic medical records in quality audits represents an invaluable advance for services, as it assists in the standardization of care, service provision and information recording.
References
Adler-Milstein, J., Adelman, J. S., Tai-Scale, M., Patel, V. L. & Dymek, C. (2020). EHR audit logs: A new goldmine for health services research? Journal of Biomedical Informatics, 101, 1-23.
Akhu-Zaheya, L., Al-Maaitah, R. & Hani, S. B. (2017). Quality of nursing documentation: Paper-based health records versus electronic-based health records. Journal of Clinical Nursing, 27(3-4), 578-589.
Aldosari, B., Al-Mansour, S., Aldosari, H. & Alazani A. (2017). Assessment of factors influencing nurses acceptance of electronic medical record in a Saudi Arabia hospital. Informatics in Medicine Unlocked, 10, 82-88.
Azzolini, E., Furia, G., Cambieri, A., Ricciardi, W., Volpe, M., & Poscia, A. (2019). Quality improvement of medical records through internal auditing: a comparative analysis. J Orev Med Hyg, 60(3), 250-255.
Barros, M. M. O., Damasceno, C. K. C. S., Coêlho, M. C. V. S. & Magalhães, J. M. (2020). Use of the patient´s eletronic medical record by the nursing team. Journaul of Nursing, 14, e241496.
Baumann, L. A., Baker, J. & Elshaug, A. G. (2017). The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy, 122(8), 827-836.
Burkoski, V., Yoon, J., Farshait, N., Hutchinson, D., Collins B. E., Solomon, S. & Grinspun, D. (2019). Optimizing Nursing Practice through Integration of Best Practice Guidelines into Electronic Medical Records. Nursing Leadership, 32, 98-107.
Cheng, D. R. & South, M. (2020). Electronic Task Management System: A Pediatric Institution’s Experience. Applied Clinical Informatics, 11(5), 839-845.
Colares, A. C. V., Pinheiro, L. E. T. & Silva, J. N. (2020). Principais assuntos de auditoria: a divulgação ainda é comunicativa após três anos de aplicação da NBC TA 701? REDECA, 7(1), 89-111.
Cordeiro, T. L. R., Andrade, L. A., Santos, S. P. & Stralhoti, K. N. O. (2019). Prontuário eletrônico como ferramenta para a sistematização da assistência de enfermagem no serviço de urgência/emergência: percepção dos enfermeiros. Rev Espaço para a Saúde, 20(2), 30-41.
Cross, D. A. & McCullough, J. S. (2019). Drivers of health information exchange use during postacute care transitions. The Americam Journal of Managed Care, 25(1), 1-18.
Cunha, D. C., Carvalho, D. N. R., Batista, A. M. V., Santos, A. P. G., Martins, J. D. N. & Souza, M. O. L. S. (2020). A percepção da equipe de enfermagem sobre a importância da segurança do paciente em um hospital público do Norte. Revista Nursing 23(260), 3511-3514.
Fabro, G. C. R., Chaves, L. D. P., Teixeira, K. R., Figueiredo, M. F., Maurin, V.P. & Gleriano, J. S. (2020). Auditoria em saúde para qualificar a assistência: uma reflexão necessária. Cuid. Enferm., 14(2), 147-155.
Freitas, S. R. Jr. (2020). Qualidade dos registros de enfermagem em unidade de terapia intensiva: contribuição nos processos de auditoria e assistência em saúde. Electronic Journal Collection Health, 12(12), 1-6.
Gomes, P. A. R., Farah, B. F., Rocha, R. S., Friedrich, D. B. C. & Dutra, H. S. (2019). Prontuário Eletrônico do Cidadão: Instrumento Para o Cuidado de Enfermagem. Revista de pesquisa cuidado é fundamental online, 11(5), 1226-1235.
Guedes, O. S. & Silva S. S. (2017). Origem e evolução da auditoria. Centro Universitário São Lucas, 27, 1-11.
Hernández-García, V., Vázquez-Sánchez, B. G. & Santiago-González, N. (2021). Cumplimiento del registro clínico electrónico acorde al modelo del cuidado de enfermería. Rev Enferm Inst Mex Seguro Soc, 29(3), 166-173.
Lacerda, M. R. & Costenaro, R. G. S. (2016). Metodologias da pesquisa para enfermagem e saúde da teoria à prática. Moria.
Lima, R. J., Pimenta, C. J. L., Frazão, M. C. L. O., Silva, C. R. R., Viana, L. R. C. & Salvano, G. R. (2018). Auditoria de enfermagem: revisão integrativa da literatura. Revista Nursing, 21(247), 2531-2534.
Luz, A., Martins, A. P. & Dynewicz A. M. (2007). Características de anotações de enfermagem encontradas em auditoria. Revista Eletrônica de Enfermagem, 9(2), 344-361.
Mancilla-Salcedo, B. A. & Santiago-González, N. (2020). Experiencia del profesional de enfermería en el uso y desarrollo del expediente clínico electrónico. Rev Enferm Inst Mex Seguro Soc, 28(3), 262-267.
Mansoori, M. H., Benjamin, K., Ngwakongnwi, E. & Abdulla, S. A. (2019). Nurses’ perceptions of the clinical information system in primary healthcare centres in Qatar: a crosssectional survey. BMJ Health Care Inform, 26(1), 1-7.
Moldskred, P. S., Snibsoer, A. K. & Espehaug, B. (2021). Improving the quality of nursing documentation at a residential care home: a clinical audit. BMC Nursing, 20(103), 1-7.
Nost, T. H., Frigstad, S. A. & Andre, B. (2017). Impact of education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital. Nordic Journal of Nursing Research, 37, 100-108.
Picchiai, D. & Rodrigues, C. (2019). Prontuário eletrônico do paciente de uma pequena unidade ambulatorial: processo sistêmico e indicadores hospitalares. Revista Horizontes Interdisciplinares da Gestão, 3(2), 127-152.
Pontefract, S. K. & Wilson, K. (2019). Using electronic patient records: defining learning outcomes for undergraduate education. BMC Medical Education 19(30), 1-8.
Ramukumba, M. M. & Amouri, S. E. (2019). Nurses’ perspectives of the nursing documentation audit process. Health SA, 24, 1-7.
Robert, N. (2019). How artificial intelligence is changing nursing. Nursing Management, 50(9), 30–39.
Rother, E. T. (2007). Revisão sistemática X revisão narrativa. Acta paul. enferm., 20(72), 1-12.
Tai-Seale, M., Dillon, E. C., Yang, Y., Nordgren, R., Steinberg, R. L., Nauenberg, T. & Frosh, D. L. (2019). Physicians’ Well-Being Linked to In-Basket Messages Generated by Algorithms in Electronic Health Records. Health Affairs, 38, 1073-1078.
Tubaishat, A. (2017). Perceived usefulness and perceived ease of use of electronic health records among nurses: Application of Technology Acceptance Model. Informatics for Health and Social Care, 43(4), 379-389.
Wang, N., Yu, P., & Hailey, D. (2015). The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study. International Journal of Medical Informatics, 84(4), 561–569.
World Health Organization [WHO]. (2016). 10 facts on patient safety. http://www.who.int/features/factfiles/patient_safety/patient_safety_facts/en/index8.html.
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