Definition, structure, content, use and impacts of electronic health records: A review of the research literature

The multivoicedness of written documentation: An international nursing student documenting in a second language

“…For instance, due to criticisms of the time-consuming nature of the oral reporting tradition, there has been a tendency to move gradually towards electronic patient records instead (Valta 2013). There are a few studies on Finnish report documents (see Haapakorpi and Haapola 2008;Tiililä 2011), yet some are related to the use of EPRs (see Häyrinen, Saranto and Nykänen 2008;Karvinen 2009;Valta 2013). When it comes to language use in EPRs, different language varieties face the formal regulations for written documentation.…”

NETIMIS: Dynamic Simulation of Health Economics Outcomes Using Big Data

“…EHR systems evolved from paper-based physician notes and the requirement to structure these more formally, and eventually computerize, as health organizations have grown in size and complexity. Patient level information including demographic data and some clinical information (for example allergies, long term conditions) is supplemented by time-stamped records recording observations, diagnosis, prescriptions, treatment and administrative processes such as admission and discharge [21]. These events may be supplemented by attached images, documents and data files (for example ultrasound images, scans of letters received and biometric data) [22].…”

Contribuições dos registros eletrônicos para a segurança do paciente em terapia intensiva: uma revisão integrativa

“…24 Several studies support this perspectives and add new possibilities, such as: improvement of practice environments, direct care, patient results and satisfaction; reduction in the time spent on documentation and clinical record keeping; development and improvement of clinical reasoning skills and judgment; inclusion of nurses in intensive care processes; promotion of clinical discussions among colleagues and the multidisciplinary team; support of the continuous search for information aimed at generating evidence-based care; and guarantee of the continuity of nursing care. 17,19,21,[25][26][27][28][29][30][31][32][33][34] However, in order to provide nurses with the ability to carry out the documentation of rendered care processes, studies point to the need to standardize data entries included in the electronic health record, as well as recover and analyze information by means of a vocabulary that standardizes the clinical terms of the care practice. The standardization of these clinical terms must meet specified criteria such as validity, specificity, data recovery and ease of communication, and must be presented in a way that supports the understanding, knowledge and intuition of the professionals.…”

“…The standardization of these clinical terms must meet specified criteria such as validity, specificity, data recovery and ease of communication, and must be presented in a way that supports the understanding, knowledge and intuition of the professionals. [34][35][36] In 2003, the International Organization for Standardization (ISO) elaborated the "Reference Terminology Model for Nursing", which they named ISO 18104. In addition to accommodating several terminologies and classifications most frequently used by nurses for patient data recording, ISO 18104 also facilitates the combination of nursing terms with other health standards/ terminologies, aiming to promote the necessary integration of information systems.…”

“…In nursing practice, the data collected in the Nursing Process record can and must be standardized, thus facilitating nursing actions and decision-making processes, as well as developing research and assisting in the production of information aimed at assessing the continuity, quality and results of the health care rendered to patients. 18,19,34,[36][37][38][39] In light of this reality, information and computing systems, allied with a minimum data set and/or classification terminology/system, stand out as innovative, necessary and readily available resources that are able to improve and strengthen nursing care, as well as guarantee its continuity, especially in ICUs. The advancement and enhancement of information technologies and information systems provide several possibilities to be explored in the health and nursing area, and also in the information management process, such as the introduction of new tools that can empower decision-making processes and the production of care quality indicators in the quest for better performance through the achievement of superior results in health care practice.…”