International Journal of Social Science (IJSS) Vol.
5 Issue.
3 Oktober 2025, pp: 355-362 ISSN: 2798-3463 (Printe.
| 2798-4079 (Onlin.
DOI: https://doi.
org/10.
53625/ijss.
THE ROLE OF ELECTRONIC NURSING DOCUMENTATION
IN ENHANCING PATIENT CARE QUALITY: A SYSTEMATIC
LITERATURE REVIEW
Siska Mayang Sari1.
Faridah Mohd Said2 Faculty of Nursing Lincoln University Collage.
Malaysia Email: 1siskamyg@htp.
Article Info Article history:
Received Sept 01, 2025 Revised Sept 29, 2025 Accepted Oct 02, 2025 Keywords:
Electronic Nursing Documentation.
Quality of Care.
Systematic Literature Review
ABSTRACT
Electronic nursing documentation (END) has become an essential component of modern nursing practice.
The use of END is expected to improve the quality of patient care through more accurate and efficient record keeping.
This article aims to evaluate the effectiveness of electronic nursing documentation in improving the quality of patient care.
This systematic review study was conducted in June-July 2024 by searching the literature on electronic databases such as ProQuest.
Science Direct.
PubMed, and Google Scholar for articles published between 2019 and 2024.
The keywords used included Auelectronic nursing documentationAy, or Aucomputerized nursing documentationAy and Auquality of careAy and AunurseAy AuhospitalAy.
Two reviewers independently screened the articles, extracted data, and assessed the quality of the included studies using the Systematic Reviews and Meta-Analyses (PRISMA).
There were 9 articles met the inclusion criteria and were analysed The inclusion criteria were RCT and non RCT, cross sectional and observational study, and hospital setting, while the exclusion criteria were qualitative study and literature or systematic review.
The analysis showed that the use of END significantly improved the quality of nursing care, enhanced communication and collaboration among healthcare providers, leading to improved patient outcomes.
Besides.
END improved documentation accuracy, time efficiency, operational efficiency, error reduction and patient However, some challenges such as monitoring and evaluation from nurse managers regarding the accuracy and quality of documentation and the need for computer skills training are also needed.
It Concluded the electronic nursing documentation has great potential to improve the quality of patient care in hospitals This is an open access article under the CC BY-SA license.
Corresponding Author:
Siska Mayang Sari Nursing Program.
Faculty of Health.
Universitas Hang Tuah Pekanbaru.
Riau Province.
Indonesia Email: siskamyg@htp.
INTRODUCTION
The transition from traditional paper-based nursing documentation to electronic nursing documentation (END) has garnered significant attention in recent years, particularly in the context of enhancing the quality of care in hospital Research indicates that the adoption of END can lead to substantial improvements in the quality of nursing documentation and patient care.
These findings are supported by the work of which emphasizes that electronic nursing records improve the completeness of documentation and enhance the legal aspects of nursing care, thereby providing a more robust framework for accountability (Hariyati et al.
, 2.
Furthermore, 's research points out that while electronic documentation can streamline workflows, it may inadvertently reduce the time nurses spend interacting with patients, suggesting a need for careful consideration of how these systems are designed and implemented (Gaudet, a.
Journal homepage: https://bajangjournal.
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php/IJSS International Journal of Social Science (IJSS) Vol.
5 Issue.
3 October 2025, pp: 355-362 ISSN: 2798-3463 (Printe.
| 2798-4079 (Onlin.
The effectiveness of END is also contingent upon the quality of communication it facilitates among healthcare emphasize the importance of user-friendly electronic documentation systems that do not impose excessive time burdens on nursing staff, thereby promoting better communication and collaboration in patient care (Groot et al.
Additionally, the systematic review by underscores that structured nursing records can significantly enhance the quality of documentation, which is essential for effective patient care (Saranto et al.
, 2.
However, the transition to electronic systems is not without challenges.
nurses often report feeling overwhelmed by the demands of electronic documentation, which can detract from their primary focus on patient care(Vehko et al.
, 2.
Moreover, the successful integration of END into nursing practice requires ongoing training and support for nursing staff.
found that positive perceptions of electronic health records among nurses are crucial for their effective use, highlighting the need for educational initiatives that address both the technical and practical aspects of electronic documentation (Riaz et al.
, 2.
This aligns with the findings of, who noted that while electronic systems can improve documentation quality, their effectiveness is often influenced by the perceived workload and usability issues faced by nurses (Wang et al.
, 2.
This systematic literature review aims to evaluate the effectiveness of electronic nursing documentation in improving the quality of care
RESEARCH METHODOLOGY
Literature Search Strategy This systematic review study was conducted in June-July 2024 by searching the literature on electronic databases such as ProQuest.
Science Direct.
PubMed, and Google Scholar.
The keywords used included Auelectronic nursing documentationAy, or Aucomputerized nursing documentationAy and Auquality of careAy and AunurseAy AuhospitalAy.
The inclusion criteria encompassed peer-reviewed articles published in English from 2019 to 2024 that focused on the impact of END on nursing care quality within hospital settings, study design is RCT and non RCT, cross sectional and observational study, while the exclusion criteria were qualitative study and literature or systematic review, and involved studies that did not specifically address electronic nursing documentation.
Selection studies The selection process involved two independent reviewers who screened the titles and abstracts of the identified Full-text articles were retrieved for those that met the inclusion criteria.
Discrepancies between reviewers were resolved through discussion, and a third reviewer was consulted when necessary.
The final selection aimed to include studies that provided empirical evidence regarding the effects of END on quality of care, as well as those that explored the contextual factors influencing these outcomes.
Data Extraction Data from the selected studies were extracted using the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).
To assess the quality of included studies were used COCHRANE ROB 2.
for the Randomized Controlled Trial (RCT) studies, and STROBE for Non RCT and observational studies.
Journal homepage: https://bajangjournal.
com/index.
php/IJSS International Journal of Social Science (IJSS) Vol.
5 Issue.
3 Oktober 2025, pp: 355-362 ISSN: 2798-3463 (Printe.
| 2798-4079 (Onlin.
DOI: https://doi.
org/10.
53625/ijss.
Figure 1.
PRISMA flow chart, selection of studies Author Laith.
Adnan A Table 1.
Electronic nursing documentation to quality care Title Year Design Result Electronic nursing 2023 Randomized The results revealed controlled trial that electronic nursing interventions to documentation has promote or improve improved quality of Safety and/or Enhanced quality care in an communication and acute setting collaboration among healthcare providers can potentially result in improved patient outcomes - The implementation of electronic nursing documentation in hospital settings has demonstrated a positive impact on the quality of documentation, operational efficiency, error reduction, and enhancement of patient a.
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3 October 2025, pp: 355-362 ISSN: 2798-3463 (Printe.
| 2798-4079 (Onlin.
Pure,Deoyani.
Ambad.
Meghali N.
Kaple.
Dighade A Review on Association between Electronic Health Record use and Quality of Patient Care 2022 Observational Karp,E.
Freeman, ,Simpson,K.
,Simpson,A.
Changes in Efficiency and Quality of Nursing Electronic Health Record Documentation After Implementation of an Admission Patient History Essential Data Set Non RCT Cohort Dinari,F.
Bahaadinbeigy,K.
Bassiri,S.
Mashouf,E.
Bastaminejad .
Moulaei.
Benefits, barriers, and facilitators of using speech technology in documentation and reporting: A crosectional study Crosectional Hussein.
Khalip.
Hashim.
Harun.
Eazilah .
Mat Shah.
N Pyron.
Lesley CarterTempleton.
Heather Patient Care CrossDelivery: Electronic Sectional Nursing Study Documentation in Malaysia Improved Patient 2019 Cohort Study Flow and Provider Efficiency After the Implementation of an Electronic Health Record EMRs help store and manage patient data, medical history, and EMRs save time for healthcare providers by eliminating the need for paper documentation and accurately storing past health information.
The use of EMRs improves the quality of patient care.
The capture of essential data elements improved by almost 6%, and admission patient history data completed in one sequence increased by 24%.
These study results demonstrate that system timers and event logs can measure the preintervention and postintervention changes in efficiency and quality of a defined clinical workflow into an electronic health record By providing information on the benefits, barriers, and facilitators of using this technology, hospital managers, nursing managers, and information technology managers of healthcare canters can make more informed decisions in selecting and implementing SRS for nursing report Nurses had a higher knowledge level of and positive attitudes toward electronic nursing Implementing an electronic health record in six urgent care clinics led to improved provider efficiency and patient flow, with an average length of stay decreasing from 109 minutes to 73 minutes.
Journal homepage: https://bajangjournal.
com/index.
php/IJSS International Journal of Social Science (IJSS) Vol.
5 Issue.
3 Oktober 2025, pp: 355-362 ISSN: 2798-3463 (Printe.
| 2798-4079 (Onlin.
DOI: https://doi.
org/10.
53625/ijss.
Fabio D'Agostino.
Valentina Zeffiro.
Antonello Cocchieri.
Mariangela Vanalli.
Davide Ausili.
Ercole Vellone.
Maurizio Zega.
Rosaria Alvaro Impact of an Electronic Nursing Documentation System on the Nursing Process Accuracy RCT A significant improvement .
in nursing documentation accuracy scores was shown after PAI (Professional Assessment Instrument.
implementation Kana Kodama.
Shozo Konishi.
Manabe.
Katsuki Okada.
Junji Yamaguchi.
Shoya Wadal.
Kento Sugimoto.
Sakiko Itoh.
Daiyo Takahashi.
Ryo Kawasaki.
Yasushi Matsumura.
Toshihiro Takeda Impact of an Electronic Medical Record-Connected Questionnaire on Efficient Nursing Documentation:
Usability and Efficacy Study Ouasy Experiment The study developed and implemented a system in which self- reported patient data were captured in the hospital information network and quoted in the nursing This system contributes to improving the efficiency of nurses' task H Halimatussakdiah.
Iskandar Faisal.
Cut Aja Nuraskin.
Aripin Ahmad.
Alhuda The Effect of Electronic Nursing Documentation (END) Implementation on Nursing Services Toward Patients' Satisfaction Crosectional nurses can provide comprehensive nursing care comprehensive nursing care to patients by using digital documentation (Electronic Nursing Documentation The use of Electronic Nursing Documentation (END) can increase patient satisfaction through shar'i ethics and good nurse performance.
Of all the variables tested in the development of the model, shari'i ethics affect the increase in patient The SEM test results obtained the GFI (Goodness of Fit Inde.
value is in the range of Cut of Value expected .
Value 0.
The use of END in nursing services and supported by shar'i ethics and good nurse performance can increase postoperative patient
RESULT
Nine articles were included in the final review.
This study explains the implementation of END toward patient The collective evidence from these studies underscores the significant benefits of electronic nursing documentation and electronic health records in enhancing the quality of patient care, improving operational efficiency, and increasing patient satisfaction.
This systematic review synthesizes findings from various studies examining the impact of electronic nursing documentation (END) and electronic health records (EHR) on patient care quality, nursing efficiency, and overall healthcare outcomes.
The studies included in this review utilized diverse methodologies, including randomized a.
Journal homepage: https://bajangjournal.
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php/IJSS International Journal of Social Science (IJSS) Vol.
5 Issue.
3 October 2025, pp: 355-362 ISSN: 2798-3463 (Printe.
| 2798-4079 (Onlin.
controlled trials (RCT.
, observational studies, cohort studies, and cross-sectional studies, providing a comprehensive overview of the current landscape in electronic documentation practices.
Electronic Nursing Documentation and Quality of Care (Adnan, 2.
conducted a randomized controlled trial that demonstrated significant improvements in nursing quality due to the implementation of electronic nursing documentation.
The study highlighted enhanced communication and collaboration among healthcare providers, which are critical components for improving patient Furthermore, the research indicated that the use of electronic documentation positively affected operational efficiency, reduced errors, and enhanced patient safety.
Electronic Medical Records (EMR.
and Patient Care (Pure et al.
, 2.
performed an observational study that established a correlation between the use of EMRs and the quality of patient care.
Their findings indicated that EMRs facilitate the storage and management of patient data, streamline healthcare providers' workflows by eliminating paper documentation, and ultimately improve the quality of care delivered to patients.
Efficiency and Quality in Nursing Documentation (Karp et al.
, 2.
reported on a non-randomized cohort study that focused on the implementation of an essential data set for admission patient history within EHRs.
The results showed a nearly 6% improvement in the capture of essential data elements and a 24% increase in the completion of admission patient history data in a single This study underscored the effectiveness of system timers and event logs in measuring changes in efficiency and quality in clinical workflows.
Speech Recognition Technology in Nursing Documentation (Dinari et al.
, 2.
conducted a cross-sectional study that explored the benefits, barriers, and facilitators of using speech recognition technology (SRT) in nursing documentation.
The findings suggested that understanding these factors could assist hospital and nursing managers in making informed decisions regarding the selection and implementation of SRT for nursing report documentation.
Nurses' Knowledge and Attitudes Towards Electronic Documentation (Hussein et al.
, 2.
carried out a cross-sectional study in Malaysia, revealing that nurses exhibited a higher level of knowledge and positive attitudes towards electronic nursing documentation.
This finding is crucial as it indicates the potential for successful implementation and utilization of END systems in nursing practice.
Impact of EHR on Patient Flow and Provider Efficiency (Pyron & Carterleton, 2.
reported on a cohort study that assessed the effects of EHR implementation in urgent care clinics.
The results indicated a significant improvement in provider efficiency and patient flow, with the average length of stay decreasing from 109 minutes to 73 minutes, demonstrating the operational benefits of EHR Nursing Process Accuracy with Electronic Documentation (DAoAgostino et al.
, 2.
conducted an RCT that found a significant improvement in nursing documentation accuracy scores .
< .
following the implementation of Professional Assessment Instruments (PAI).
This study highlights the critical role of structured electronic documentation in enhancing the accuracy of nursing processes.
Usability and Efficacy of EMR-Connected Questionnaires (Kodama et al.
, 2.
explored the usability and efficacy of an EMR-connected questionnaire designed to capture self-reported patient data.
The study concluded that this system significantly contributes to improving the efficiency of nurses' task recordings, thereby enhancing the overall documentation process.
Patient Satisfaction and Electronic Nursing Documentation (Halimatussakdiah et al.
, 2.
investigated the effect of END implementation on nursing services and patient satisfaction through a cross-sectional study.
The findings indicated that the use of END could enhance comprehensive nursing care and increase patient satisfaction, particularly when supported by ethical nursing practices.
The structural equation modelling (SEM) results demonstrated a Goodness of Fit Index (GFI) value within the acceptable range, further validating the positive impact of END on patient satisfaction.
DISCUSSION
Electronic nursing documentation (END) is increasingly recognized as a crucial tool for enhancing the quality of healthcare delivery.
By facilitating seamless information exchange.
END strengthens communication and collaboration between healthcare providers, which is essential for coordinated patient care.
Digital documentation systems allow nurses and other healthcare professionals to access and update patient information in real time, ensuring that all team members have the most current information.
This continuous flow of data fosters a collaborative environment where providers can make timely, well-informed decisions, leading to safer and more effective patient a.
Journal homepage: https://bajangjournal.
com/index.
php/IJSS International Journal of Social Science (IJSS) Vol.
5 Issue.
3 Oktober 2025, pp: 355-362 ISSN: 2798-3463 (Printe.
| 2798-4079 (Onlin.
DOI: https://doi.
org/10.
53625/ijss.
Furthermore.
END enables standardized documentation practices, which helps eliminate inconsistencies in reporting and supports a uniform understanding of patient conditions across teams (Hussein et al.
, 2.
The implementation of electronic nursing documentation (END) has been shown to significantly enhance the quality of nursing care by streamlining documentation processes, improving data accuracy, and increasing the accessibility of patient information.
END systems enable nurses to efficiently document patient assessments, care plans, and interventions in a standardized format, which reduces variability and promotes consistency in patient With real-time access to up-to-date patient information, healthcare providers can make more informed decisions, ultimately improving the quality of care delivered.
Recent studies indicate that END has not only increased the accuracy of nursing documentation but has also supported better patient outcomes through improved communication and coordination among healthcare teams (Dinari et al.
, 2.
Moreover.
END systems enhance workflow efficiency, allowing nurses to allocate more time to direct patient care rather than administrative tasks.
By automating routine aspects of documentation, such as data entry and recordkeeping.
END reduces the manual burden on nursing staff and minimizes the likelihood of errors.
This improved efficiency in documentation processes directly translates to more available time for patient interaction and care, which is essential for meeting patientsAo needs effectively and promptly.
In a cross-sectional study, nurses reported that END improved the speed and accuracy of their documentation, contributing to higher patient satisfaction and quality of nursing care (Halimatussakdiah et al.
, 2.
Additionally.
END contributes to enhanced decision-making and quality of care by providing comprehensive, easily accessible data on patient history and treatment progress.
This centralized information repository allows for a holistic view of the patientAos condition, enabling better continuity of care across shifts and among different providers.
As a result, nurses can more effectively monitor changes in patients' health status, which is crucial for identifying and addressing potential health issues early on.
Research has shown that END systems support proactive and personalized care approaches, helping to elevate nursing care quality overall (Kodama et al.
, 2.
CONCLUSION
Electronic nursing documentation plays a critical role in improving nursing care quality by promoting documentation accuracy, increasing workflow efficiency, and supporting data-driven decision-making.
By integrating END systems into daily practice, healthcare organizations can create an environment that supports high-quality, patient-centered care and maximizes the valuable time nurses spend directly with patients.
CONFLICT OF INTEREST
The author declares no conflict of interest.
REFERENCES