Ahmadi M¹ (PhD), Gorzin Z² * (MSc), Khoshgam M³ (MSc)

  ¹ Department of Health Information Management, School of Health Management and

  Information Sciences, Iran University of Medical Sciences, Tehran, Iran

  ² Department of Health Information Technology , School of Health Management and Information Sciences,

  Tehran University of Medical Sciences, Tehran, Iran

  ³ Department of Statistics and Mathematics, School of Health Management and

  Information Sciences, Iran University of Medical Sciences, Tehran, Iran

  Received: 22 Jul 2012, Accepted: 22 Aug 2013

  Abstract

  Introduction: Nursing documentation and data entry is foremost requisite step for high quality patient care. Recently, modern information technologies caused documentation to be changed. Health settings were applied transition from paper-based recording to electronic documentation systems which is one of the most important alterations in this regard. This study aimed to assess nursing needs about methods of documentation in Electronic Health Records (EHR).

  Methods: This analytic study was conducted on 132 nurses in 2012. The study tool was a self-developed questionnaire that its validity was confirmed using experts' opinions and the reliability was measured using the Cronbach's alpha. The data was analyzed using descriptive statistics in the SPSS.

  Results: Using voice recognition and predefined templates were considered very important for documentation. For nurses, easy to use manners for data entry in the electronic system (81.9%), user training on electronic documentation (75%), and using bedside terminals (51.6%) were considered to be the highest priorities, respectively from the nurses' point of views.

  Conclusion: Electronic documentation methods, voice recognition and predefined templates were the most important priorities for nurses. Focusing on nurses' priorities and their abilities can lead to lower burden of electronic documentation and understand the benefits of Electronic Health Records.

  Key words: documentation, data entry, nursing, Electronic Health Record

  Please cite this article as follows:

  Ahmadi M, Gorzin Z, Khoshgam M. Nurses Needs Assessment on Methods of Documentation in Electronic Health Records. Hakim Research Journal 2013 16(3): 251- 257.

  * Corresponding Author: School of Health Management and Information Sciences, Shahid Yasemi Street, Valiasr Avenue, Vanak square, Tehran, Iran. E-mail: z.gorzin5@gmail.com