Evaluation of vocal-electronic nursing documentation: A comparison study in Iran.
OBJECTIVE
Documentation is a critical element in the function of the nursing team, and cannot be separated from high-quality, patient-centered care. The aim of this study was to compare the quality of nursing documentation in electronic and paper-based systems.


METHODS
A retrospective descriptive study was designed to compare the quality of nursing documentation in electronic health records (EHR) versus paper-based documentation systems before and after the application of the electronic system.


RESULTS
Analysis of data found a significant difference in the quality of nursing documentation in the two hospitals both before and after the implementation of an EHR system (p < 0.001).Quality of nursing documentation in the electronic system was significantly better than that of paper-based documentation systems.


CONCLUSIONS
Vocal-electronic systems help to improve quality of nursing documentation, suggesting this aspect may be essential to implementing a successful system in local settings.
a Iranian Research Center for HIV/AIDS , Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences , Tehran , Iran.|b Department of Nursing Education and Management, Faculty of Nursing and Midwifery , Tehran University of Medical Sciences , Tehran , Iran.
Mona
M
Mohammadi Firouzeh
c Department of Nursing Education and Management, School of Nursing and Midwifery , Iran University of Medical Sciences , Tehran , Iran.
Ezzat
E
Jafarjalal
d Faculty of Nursing and Midwifery , Tehran University of Medical Sciences , Tehran , Iran.
Hormat Sadat
HS
Emamzadeh Ghasemi
e Department of Mathematics-Statistics, Faculty of Sciences , Air University of Shahid Sattari , Tehran , Iran.
Naser
N
Bahrani
a Iranian Research Center for HIV/AIDS , Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences , Tehran , Iran.
Sara
S
Sardashti
D000328:Adult; D000367:Age Factors; D003430:Cross-Sectional Studies; D057286:Electronic Health Records / Q000592:standards*; D005260:Female; D006801:Humans; D007492:Iran; D008297:Male; D009737:Nursing Records / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*; D012189:Retrospective Studies; D012737:Sex Factors; D012959:Socioeconomic Factors; D049250:Speech Recognition Software; D014584:User-Computer Interface
Electronic health records; healthcare documentation; nursing; quality assurance