Abstract
Introduction: Electronic nursing documentation (END) is fundamental to emergency care, ensuring effective communication, patient safety, and legal accountability. However, issues such as incomplete entries, variability in documentation quality, and limited use of standardised nursing language, particularly NANDA-I, continue to challenge the delivery of accurate and holistic care.
Objective: This study analysed the use of electronic nursing documentation in the Emergency and Trauma Department (ETD) of one tertiary hospital, examined patterns of recorded information, and compared it with the NANDA-I framework.
Methodology: A qualitative document analysis was conducted using purposive sampling of END records from April 2022 to February 2025. The Nursing Process Checklist guided the evaluation of documentation content, structure, and adherence to the nursing process and NANDA-I standards. Data were analysed thematically. Ethical approval was obtained, and all records were anonymised.
Results and Discussions: Four major themes emerged: (1) Task-Orientated Documentation Over Individualised Care Planning, (2) Inconsistent Use of Standardised Terminology (NANDA-I), (3) System Constraints and Documentation Habits, and (4) Gaps in the Evaluation Phase. These findings highlight limited holistic assessment, reduced use of nursing diagnoses, and minimal evaluation of patient outcomes.
Conclusion: Electronic nursing documentation in the ETD of the tertiary hospital remains predominantly task-focused, with inconsistent use of NANDA-I terminology and notable gaps in the evaluation phase. System design, time pressure, and documentation habits shape current practices. These findings underscore the need to strengthen electronic documentation systems and support nurses through targeted training to enhance documentation quality, clinical reasoning, and patient safety.
Notes
Reference list included in separate file.
Sigma Membership
Phi Omega at-Large
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Qualitative Research
Keywords:
Electronic Nursing Documentation, Nursing Process, NANDA-I, Emergency Nursing, Emergency Nurses, Hospital Emergency Services, Nursing Records, Electronic Health Records
Recommended Citation
Ahayalimudin, Nurul'Ain, "An Analysis of Electronic Nursing Documentation in the Emergency and Trauma Department" (2026). International Nursing Research Congress (INRC). 303.
https://www.sigmarepository.org/inrc/2026/presentations_2026/303
Conference Name
37th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Toronto, Ontario, Canada
Conference Year
2026
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-09-25
An Analysis of Electronic Nursing Documentation in the Emergency and Trauma Department
Toronto, Ontario, Canada
Introduction: Electronic nursing documentation (END) is fundamental to emergency care, ensuring effective communication, patient safety, and legal accountability. However, issues such as incomplete entries, variability in documentation quality, and limited use of standardised nursing language, particularly NANDA-I, continue to challenge the delivery of accurate and holistic care.
Objective: This study analysed the use of electronic nursing documentation in the Emergency and Trauma Department (ETD) of one tertiary hospital, examined patterns of recorded information, and compared it with the NANDA-I framework.
Methodology: A qualitative document analysis was conducted using purposive sampling of END records from April 2022 to February 2025. The Nursing Process Checklist guided the evaluation of documentation content, structure, and adherence to the nursing process and NANDA-I standards. Data were analysed thematically. Ethical approval was obtained, and all records were anonymised.
Results and Discussions: Four major themes emerged: (1) Task-Orientated Documentation Over Individualised Care Planning, (2) Inconsistent Use of Standardised Terminology (NANDA-I), (3) System Constraints and Documentation Habits, and (4) Gaps in the Evaluation Phase. These findings highlight limited holistic assessment, reduced use of nursing diagnoses, and minimal evaluation of patient outcomes.
Conclusion: Electronic nursing documentation in the ETD of the tertiary hospital remains predominantly task-focused, with inconsistent use of NANDA-I terminology and notable gaps in the evaluation phase. System design, time pressure, and documentation habits shape current practices. These findings underscore the need to strengthen electronic documentation systems and support nurses through targeted training to enhance documentation quality, clinical reasoning, and patient safety.
Description
This presentation provides practical insights and strategies to upgrade emergency nursing documentation by applying the nursing process, standardised terminology, and effective evaluation methods to improve care outcomes.