Application of Electronic Health Record (EHR) In Nursing Documentation: Literature Review
Abstract
Nursing documentation in Indonesia generally uses paper and has several limitations to completeness, efficiency, and accessibility of patient information. Electronic Health Record (EHRs)-based nursing documentation is an alternative to solving nursing documentation problems. This study aimed to analyze factors influencing the implementation of EHRs in nursing documentation and their impact on nursing services. This study used a literature review with the PICOS framework. Article search using electronic databases: Google Scholar, Research Gate, PubMed, and Science Direct with the keywords related to nursing documentation and EHRs. Articles published between 2019 and 2022 were screened based on inclusion and exclusion criteria, resulting in 10 eligible articles for review. The findings showed that the successful use of EHR-based documentation is determined by nurse perception factors, leadership and organizational support, availability of infrastructure, system usability and training to improve nurses' competence. EHR improves the quality of nursing care because it is more integrated, nurses feel satisfied because it is helped, and there is time efficiency in documenting nursing care.
References
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Ausserhofer, D., Favez, L., Simon, M., & Zuniga, F. (2021). Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation : Multicenter Cross-sectional Survey Study. March. https://doi.org/10.2196/22974
Baumann, L.A., Baker, J., & Elshaug, A. . (2018). The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy, 122(8), 827–836. https://doi.org/https://doi.org/10.1016/j.healthpol.2018.05.014
Demsash, A. W., Kassie, S. Y., Dubale, A. T., Chereka, A. A., Ngusie, H. S., Hunde, M. K., Emanu, M. D., Shibabaw, A. A., & Walle, A. D. (2023). Health professionals' routine practice documentation and its associated factors in a resource-limited setting : a cross-sectional study. BMJ Health & Care Information, 30(1), 1–7. https://doi.org/10.1136/bmjhci-2022-100699
Dhamar, E.N., & Rahayu, H. . (2020). Pengalaman perawat dalam penggunaan rekam medis elektronik di rumah sakit Panti Rini Yogyakarta. Jurnal Keperawatan I CARE, 1(2), 171–180.
Diangi, Y. T., Stevens, L. A., Felsher, B. H., Pageler, N. M., & Lee, T. C. (2019). Electronic health record ( EHR ) training program identifies a new tool to quantify the EHR time burden and improves providers' perceived control over their workload in the EHR. JAMIA, 2(March), 222–230. https://doi.org/10.1093/jamiaopen/ooz003
Groot, K.D., Anke J.E. De Veer, A.J.E., Paans, W., Anneke, L., & F. (2020). Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences. International Journal of Nursing Studies, 104. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2020.103523
Hariyati, R. T.S., & Winata, I. M. N. . (2021). Nurse satisfaction level using electronic nursing documentation. Enfermeria Clinica, 2, S109–S112. https://doi.org/https://doi.org/10.1016/j.enfcli.2020.12.002
Hariyati, R.T.S., Hamid, A.Y., & Hasibuan, Z. . (2020). Usability and satisfaction of using electronic nursing documentation, lesson learned from new system implementation at a hospital in Indonesia. International Journal of Healthcare Management, 13(1), 45–52. https://doi.org/https://doi.org/10.1080/20479700.2018.1504387
Kaipio, J., Kuusisto, A., Hyppönen, H., Heponiemi, T., & Lääveri, T. (2020). International Journal of Medical Informatics Physicians' and nurses' experiences on EHR usability : Comparison between the professional groups by employment sector and system brand. International Journal of Medical Informatics, 134(June 2019), 104018. https://doi.org/10.1016/j.ijmedinf.2019.104018
Karp, E. L., Freeman, R., Simpson, K. N., & Simpson, A. N. (2019). Changes in Efficiency and Quality of Nursing Electronic Health Record Documentation After Implementation of an Admission Patient History Essential Data Set. May, 260–265. https://doi.org/10.1097/CIN.0000000000000516
Kinnunen. (2019). Factors Related to Health Informatics Competencies for Nurses—Results of a National Electronic Health Record Survey. Computers, Informatics, Nursing, 37(8), 420–429. https://doi.org/10.1097/CIN.0000000000000511
Lindsay, M.R., & Lytle, K. (2022). Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record. Applied Clinical Information, 13(3), 711–719. https://doi.org/10.1055/a-1868-6431
Mansuri, F. (2022). Effectiveness and evaluation of electronic nursing documentation programme in terms of nurses' perception and quality of nursing documentation in selected hospital of Rajasthan. International Journal of Recent Advances in Multidisciplinary Research, 9(10), pp.8024-8031. https://www.researchgate.net/publication/367127585%0D
Pratama, M.H., & Darnoto, S. (2017). Analisis strategi pengembangan rekam medis electronic di instalasi rawat jalan RSUD kota Jogyakarta. JMIKI, 5(1), 34–45.
Riyani, E., Tutik, R., & Hariyati, S. (2022). Literature review: Kepuasan perawat dalam pendokumentasian asuhan keperawatan menggunakan sistem informasi di rumah sakit. Jurnal Keperawatan Muhammadiyah, 7(2).
Sugiharto., A. F., & Adi, M. S. (2022). Jurnal Ilmu Kesehatan Masyarakat. Jurnal Ilmu Kesehatan Masyarakat, 11(2), 186–196.
Takaredas. Y, Q., & Hariyati. R, S. (2022). Manfaat penggunaan dokumentasi asuhan keperawatan berbasis elektronik di puskesmas. Journal Cakrawala Ilmiah, 1(5), 1081–1090.
Tarigan, R., & Handiyani, H. (2019). Manfaat Implementasi Dokumentasi Asuhan Keperawatan Berbasis Komputerisasi Dalam Meningkatkan Mutu Asuhan Keperawatan. 08(2), 110–116.
Vehko, T., Hyppönen, H., Puttonen, S., Kujala, S., Ketola, E., & Tuukkanen, J. (2019). Experienced time pressure and stress : electronic health records usability and information technology competence play a role. 1–9.
Wardani, G.I., Tri, K., Suhendar, S. (2022). Kompetensi Perawat, Sarana Prasarana terhadap Dokumentasi Keperawatan Elektronik, Dampaknya pada Patient Safety. Jurnal Keperawatan, Vol 4 (3), 567–574.
Whalen, K., Grella, P., Snydeman, C., Dwyer, A., & Yager, P. (2021). Nursing Attitudes and Practices in Code Documentation Employing a New Electronic Health Record. Applied Clinical Information, 12(3), 589–596. https://doi.org/10.1055/s-0041-1731340.
Yustina. A., Zamzami.E, M., & Z. . (2020). Pengaruh penerapan Electronic Health Record (EHR) terhadap perkembangan kognitif perawat: literatur review. Indonesian Academia Health Sciences Journal, I(I), 13–16.
Ausserhofer, D., Favez, L., Simon, M., & Franziska, Z. (2021). Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation : Multicenter Cross-sectional Survey Study Corresponding Author : 9(3), 1–14. https://doi.org/10.2196/22974
Ausserhofer, D., Favez, L., Simon, M., & Zuniga, F. (2021). Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation : Multicenter Cross-sectional Survey Study. March. https://doi.org/10.2196/22974
Baumann, L.A., Baker, J., & Elshaug, A. . (2018). The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy, 122(8), 827–836. https://doi.org/https://doi.org/10.1016/j.healthpol.2018.05.014
Demsash, A. W., Kassie, S. Y., Dubale, A. T., Chereka, A. A., Ngusie, H. S., Hunde, M. K., Emanu, M. D., Shibabaw, A. A., & Walle, A. D. (2023). Health professionals' routine practice documentation and its associated factors in a resource-limited setting : a cross-sectional study. BMJ Health & Care Information, 30(1), 1–7. https://doi.org/10.1136/bmjhci-2022-100699
Dhamar, E.N., & Rahayu, H. . (2020). Pengalaman perawat dalam penggunaan rekam medis elektronik di rumah sakit Panti Rini Yogyakarta. Jurnal Keperawatan I CARE, 1(2), 171–180.
Diangi, Y. T., Stevens, L. A., Felsher, B. H., Pageler, N. M., & Lee, T. C. (2019). Electronic health record ( EHR ) training program identifies a new tool to quantify the EHR time burden and improves providers' perceived control over their workload in the EHR. JAMIA, 2(March), 222–230. https://doi.org/10.1093/jamiaopen/ooz003
Groot, K.D., Anke J.E. De Veer, A.J.E., Paans, W., Anneke, L., & F. (2020). Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences. International Journal of Nursing Studies, 104. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2020.103523
Hariyati, R. T.S., & Winata, I. M. N. . (2021). Nurse satisfaction level using electronic nursing documentation. Enfermeria Clinica, 2, S109–S112. https://doi.org/https://doi.org/10.1016/j.enfcli.2020.12.002
Hariyati, R.T.S., Hamid, A.Y., & Hasibuan, Z. . (2020). Usability and satisfaction of using electronic nursing documentation, lesson learned from new system implementation at a hospital in Indonesia. International Journal of Healthcare Management, 13(1), 45–52. https://doi.org/https://doi.org/10.1080/20479700.2018.1504387
Kaipio, J., Kuusisto, A., Hyppönen, H., Heponiemi, T., & Lääveri, T. (2020). International Journal of Medical Informatics Physicians' and nurses' experiences on EHR usability : Comparison between the professional groups by employment sector and system brand. International Journal of Medical Informatics, 134(June 2019), 104018. https://doi.org/10.1016/j.ijmedinf.2019.104018
Karp, E. L., Freeman, R., Simpson, K. N., & Simpson, A. N. (2019). Changes in Efficiency and Quality of Nursing Electronic Health Record Documentation After Implementation of an Admission Patient History Essential Data Set. May, 260–265. https://doi.org/10.1097/CIN.0000000000000516
Kinnunen. (2019). Factors Related to Health Informatics Competencies for Nurses—Results of a National Electronic Health Record Survey. Computers, Informatics, Nursing, 37(8), 420–429. https://doi.org/10.1097/CIN.0000000000000511
Lindsay, M.R., & Lytle, K. (2022). Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record. Applied Clinical Information, 13(3), 711–719. https://doi.org/10.1055/a-1868-6431
Mansuri, F. (2022). Effectiveness and evaluation of electronic nursing documentation programme in terms of nurses' perception and quality of nursing documentation in selected hospital of Rajasthan. International Journal of Recent Advances in Multidisciplinary Research, 9(10), pp.8024-8031. https://www.researchgate.net/publication/367127585%0D
Pratama, M.H., & Darnoto, S. (2017). Analisis strategi pengembangan rekam medis electronic di instalasi rawat jalan RSUD kota Jogyakarta. JMIKI, 5(1), 34–45.
Riyani, E., Tutik, R., & Hariyati, S. (2022). Literature review: Kepuasan perawat dalam pendokumentasian asuhan keperawatan menggunakan sistem informasi di rumah sakit. Jurnal Keperawatan Muhammadiyah, 7(2).
Sugiharto., A. F., & Adi, M. S. (2022). Jurnal Ilmu Kesehatan Masyarakat. Jurnal Ilmu Kesehatan Masyarakat, 11(2), 186–196.
Takaredas. Y, Q., & Hariyati. R, S. (2022). Manfaat penggunaan dokumentasi asuhan keperawatan berbasis elektronik di puskesmas. Journal Cakrawala Ilmiah, 1(5), 1081–1090.
Tarigan, R., & Handiyani, H. (2019). Manfaat Implementasi Dokumentasi Asuhan Keperawatan Berbasis Komputerisasi Dalam Meningkatkan Mutu Asuhan Keperawatan. 08(2), 110–116.
Vehko, T., Hyppönen, H., Puttonen, S., Kujala, S., Ketola, E., & Tuukkanen, J. (2019). Experienced time pressure and stress : electronic health records usability and information technology competence play a role. 1–9.
Wardani, G.I., Tri, K., Suhendar, S. (2022). Kompetensi Perawat, Sarana Prasarana terhadap Dokumentasi Keperawatan Elektronik, Dampaknya pada Patient Safety. Jurnal Keperawatan, Vol 4 (3), 567–574.
Whalen, K., Grella, P., Snydeman, C., Dwyer, A., & Yager, P. (2021). Nursing Attitudes and Practices in Code Documentation Employing a New Electronic Health Record. Applied Clinical Information, 12(3), 589–596. https://doi.org/10.1055/s-0041-1731340.
Yustina. A., Zamzami.E, M., & Z. . (2020). Pengaruh penerapan Electronic Health Record (EHR) terhadap perkembangan kognitif perawat: literatur review. Indonesian Academia Health Sciences Journal, I(I), 13–16.
Published
2026-06-02
How to Cite
ZAKIYAH, Ana; ISWATI, Iswati; BASUKI, Duwi.
Application of Electronic Health Record (EHR) In Nursing Documentation: Literature Review.
Adi Husada Nursing Journal, [S.l.], v. 12, n. 1, p. 9-19, june 2026.
ISSN 2502-2083.
Available at: <https://adihusada.ac.id/jurnal/index.php/AHNJ/article/view/606>. Date accessed: 02 july 2026.
doi: https://doi.org/10.37036/ahnj.v12i1.606.
Section
Articles
Keywords
Nursing Documentation, Electronic Health Record (EHR), Nurses
This work is licensed under a Creative Commons Attribution 4.0 International License.
