Study: Accuracy Issues Plague Paper Records and EHRs

Whenever debates about paper records versus electronic health records (EHRs) erupt, parties on both sides of the issue inevitably cite data accuracy and readability as concerns for both formats. However, a new study finds that both sides have a point. In terms of nursing documentation, a study published in the Journal of Clinical Nursing determined that “both forms of documentation revealed drawbacks in terms of content, process, and structure.”

The study, which assessed and compared the quality of nursing documentation in both electronic and paper records, used a retrospective, descriptive, comparative design. Investigators audited 434 records for both paper-based health records and EHRs from medical and surgical wards. Researchers used the Cat-ch-Ing Audit Instrument—a 17-question auditing tool designed to assess nursing documentation—to review both sets of records.

The researchers concluded that both types of documentation have their drawbacks and benefits.

“EHRs were better than paper-based health records in terms of process and structure. In terms of quantity and quality content, paper-based records were better than EHRs,” the study states. “The study affirmed the poor quality of nursing documentation and lack of nurses’ knowledge and skills in the nursing process and its application in both paper-based and electronic-based systems.”

Additionally, the study authors recommend that providers should continue to be trained on documentation best practices, and that health policies and actions, “should focus on improving nursing knowledge, competencies, practice in nursing process, enhancing the work environment and nursing workload, as well as strengthening the capacity building of nurses practice to improve the quality of nursing care and patients’ outcomes.”

Click here to read the abstract.

Mary Butler is the associate editor at The Journal of AHIMA.

Submit a Comment

Your email address will not be published. Required fields are marked *

Share This

Share This

Share this post with your friends!