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Informatics for Health and Social Care

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Evaluation of vocal-electronic nursingdocumentation: A comparison study in Iran

Mona Mohammadi Firouzeh, Ezzat Jafarjalal, Hormat Sadat EmamzadehGhasemi, Naser Bahrani & Sara Sardashti

To cite this article: Mona Mohammadi Firouzeh, Ezzat Jafarjalal, Hormat Sadat EmamzadehGhasemi, Naser Bahrani & Sara Sardashti (2016): Evaluation of vocal-electronic nursingdocumentation: A comparison study in Iran, Informatics for Health and Social Care, DOI:10.1080/17538157.2016.1178119

To link to this article: http://dx.doi.org/10.1080/17538157.2016.1178119

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Evaluation of vocal-electronic nursing documentation:A comparison study in IranMona Mohammadi Firouzeha,b, Ezzat Jafarjalalc, Hormat Sadat Emamzadeh Ghasemid,Naser Bahranie, and Sara Sardashtia

aIranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University ofMedical Sciences, Tehran, Iran; bDepartment of Nursing Education and Management, Faculty of Nursing andMidwifery, Tehran University of Medical Sciences, Tehran, Iran; cDepartment of Nursing Education and Management,School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran; dFaculty of Nursing andMidwifery, Tehran University of Medical Sciences, Tehran, Iran; eDepartment of Mathematics–Statistics, Faculty ofSciences, Air University of Shahid Sattari, Tehran, Iran

ABSTRACTAim:Documentation is a critical element in the function of the nursing team, andcannot be separated from high-quality, patient-centered care. The aim of thisstudy was to compare the quality of nursing documentation in electronic andpaper-based systems.Method:A retrospective descriptive study was designed tocompare the quality of nursing documentation in electronic health records (EHR)versus paper-based documentation systems before and after the application ofthe electronic system. Results: Analysis of data found a significant difference inthe quality of nursing documentation in the two hospitals both before and afterthe implementation of an EHR system (p < 0.001).Quality of nursing documenta-tion in the electronic system was significantly better than that of paper-baseddocumentation systems. Conclusion: Vocal-electronic systems help to improvequality of nursing documentation, suggesting this aspect may be essential toimplementing a successful system in local settings.

KEYWORDSElectronic health records;healthcare documentation;nursing; quality assurance

Introduction

Nursing documentation is the record of provided care to the patients admitted to different hospital wards.The goal of this record is to empower health-care systems through standardized patient care. Properdocumentation is a fundamental component of patient care because it facilitates communication betweenphysicians, nurses, and other health-care providers, which is a key element in quality care (1,2).Documenting executed tasks is also considered an integral component of the so-called “nursing process”.The nursing process is a recognized scientific method for patient-oriented care that comprised of sixphases: 1) patient/client assessment; 2) primary nursing diagnosis; 3) outcome/goal identification; 4)planning to achieve goals; 5) implementing defined plans and documenting the process; and 6) evaluationof nursing care (3–6).

To achieve high standards of clinical medicine and nursing, it is imperative that the process ofdocumentation is done consistently and properly among health-care providers, yet setting up a system todo so remains a constant challenge (7). Shortcomings in the documentation of nursing care results inineffective service provision (8); for this reason, standard tools to evaluate patient records are utilizedamong nursing teams and managers; these measures are important in providing high-quality service inanymedical setting (9). Additionally, nursing reports are the only viable legal record of the executed tasksand the best evidence to be offered in cases of negligence complaints (10).

CONTACT Ezzat Jafarjalal jafarjalal.e@iums.ac.ir Department of Nursing Education and Management, School of Nursingand Midwifery, Iran University of Medical Sciences, Rashid Yasemi Street, Valiasr Avenue, Tehran 1996713883, Iran.© 2016 Taylor & Francis

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Quality of nursing documentation seems to be well grasped by professionals involved in patient care.Donabedian explains “quality” using three interconnected constructs—process, structure, and outcomes(11), while Mahler et al. introduce a more comprehensive picture of the different aspects of nursingdocumentation, including but not limited to the following factors: adequacy of documentation of theprocess, explanation of the course of care, participation in care plan, and reasonability (12). Existingliterature suggests potential shortcomings in the quality of nursing records in Iran. Several studies haveshown substantial instances of undocumented or incomplete registration of executed tasks in differenthospital wards (13–15).

Paper-based documentation is the traditional recording method, and it is still used in manyhospitals. Paper documents, if done properly, comply with the requisites of nursing process.Nonetheless, many limitations regarding the quality and acceptance of this method have beenreported worldwide (16). The significant time spent on writing reports, illegible records, andinaccurate or unregistered information that result in medical errors are considered to be amongthe major defects of this system (17,18). These challenges and concerns have led many health-careproviders to shift away from the traditional paper-based documentation system and toward acomputerized approach to documenting patient care (19). Hence, the introduction and implementa-tion of computer-based tools (the electronic health-care record or EHR) is considered to be a meansfor improving existing settings to support nursing process and patient care (20–23).

Various applications have been developed since the introduction of these new computer-based EHRtechnologies into health-care and nursing documentation. These novel approaches have assistedhealth-care systems in improving their provided quality of care and also helped reduce health-carecosts (24). One of the main advantages of EHR documentation, compared to paper-based documenta-tion, for health professionals is the convenient access to more comprehensive, precise, and up-to-dateinformation regarding patient care (25,26). Evidence also suggests better outcomes (e.g., reducedmortality and morbidity), improved quality of care, lower expenditures, and fewer medical errors (27–29). However, some health-care providers have been reluctant in implementing EHR systems due tofinancial and legal worries as well as technological barriers (30–32). The latter include adjustmentsrequired in standards of care provided by the current system and the need to train staff on theappropriate use of the technology, which also complicates the process of change (33). Lee et al. revealedthat nurses’ acceptance of EHR documentation was influenced by their perception of advantages,intricacy, and compatibility with accessible experiences and training (34). The inappropriate use ofautomated processes may lead to mistakes at the bedside, making it imperative that all personnel aretrained properly, which may be quite expensive to do at some institutions (35).

One of the many EHR technologies that have been implemented in Iran is an electronic voice-record orvoice-recognition system, currently implemented in a single hospital (Hasheminejad Hospital, Tehran). Inthis system, voice files are made for admitted patients to document the details of offered services andprocedures. There is a lack of knowledge about the applicability of this relatively new system, so it iscurrently unknownwhether such a system provides any benefits of improved quality to patient care in localhospitals. Most of the existing literature is focused on paper-based documentation in different countries ofthe region (11–13). Considering this gap of knowledge about the benefits of computer systems, we decidedto conduct the present study to evaluate paper-based versus vocal-electronic documentation systems in tworeferral hospitals of Tehran. We investigated whether there were any changes in the quality of nursingdocumentation before and after the introduction of vocal-electronic documentation.

Methods and materials

Study design and sample

In a cross-sectional study to evaluate the quality of nursing documentation in vocal-electronic versuspaper-based systems, two hospitals were evaluated before and after the implementation of the newsystem in the years 2008 and 2012.

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The study was conducted in two referral hospitals of Tehran affiliated with the Tehran Universityof Medical Sciences (TUMS). Selected wards of these two hospitals were assessed individually andthen compared to achieve the study objectives. The leading center in the implementation of vocal-electronic documentation in Iran (Hasheminejad Hospital) was considered the index hospital toassess potential changes in the quality of nursing records. To further evaluate other influencingfactors, we selected another hospital (Firoozgar Hospital) with similar higher organization systems,in-service nursing personnel, and continuous nursing education. Intra-hospital training was sched-uled seasonally in Firoozgar Hospital, while Hasheminejad Hospital had monthly educationalcourses. Although sub-organizational differences in individual hospital training courses existed,both hospitals had devoted more time to principles and quality of nursing records in educationalprograms in the interval between 2008 and 2012.

The urologic surgery wards in the two hospitals were evaluated for the purposes of the presentstudy. We chose this particular ward because patients admitted to these wards usually have a definitediagnosis, the care provided during their hospital stay can be monitored at different stages (pre- andpostoperation), and they are not generally admitted for long periods of time.

Documentation systems

Vocal-electronic systemThe digital voice-record system in Hasheminejad Hospital is an innovative documentation systemutilized in all hospital wards since 2008. All nursing staff in the ward are identified by an individualdigital code to access the network and their personal accounts. After opening their accounts, nursesmay record a new voice file for each patient during a working shift to document executed services,prescriptions, and procedures. An explanation section can be added to each patient’s record if extrainformation (i.e., critical changes in physical state) is needed. Records can be edited before they areregistered by the nurse; however, after the final registration, there can be no further editing of theexisting file, and a new file should be made when necessary.

Before the initiation of the study, the management group and nursing staff were interviewedregarding their viewpoints about the advantages of the vocal-electronic system. Advantages men-tioned included less time spent on preparing records, easy and quick access to patient files, andeconomic benefits including the reduced need for paper. Despite the mentioned advantages, severallimitations were also pointed out. One important limitation is that the system operation depends onthe hospital’s computer network and is not functional if it is not connected to this network or if thenetwork is down. The other issue comes up with legal cases, where voice records are not as easilyaccessible and long-lasting as paper documentation.

Paper-based documentationPaper-based documentation is considered to be the routine documentation system implemented inmost referral hospitals and tertiary centers all over the country, including the hospital considered asthe control. In the traditional system, nurses have to fill out charts recording patients’ vital signsbased on physician orders as well as write notes in the end of patients’ files to document services,prescriptions, and physical findings.

Ethical considerations

The Ethical Review Boards of TUMS reviewed and approved of the study protocol. Access toregistered files was allowed by the management systems of the two hospitals upon this permission.No identifying data were documented from the files investigated by the researchers.

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Data collection

Study sampleBased on sample size calculations (with a 95% confidence interval; β = 0.9) and considering theprobability of missing data, 120 patient records in the years 2008 and 2012 were randomly selectedfrom the two hospitals; 60 records from each hospital were evaluated through structured checklistsbefore and after the implementation of the vocal-electronic system. Allocation of the two hospitalswas based on nursing documentation systems in use.

Measurement toolsAll relevant data including age, gender, and years of experience of the head nurses and staff of thetwo selected wards were documented to confirm consistency between the two sampling venues. Forfurther assessment, the following checklists were designed and filled out:

(1) Demographic characteristics: Demographic features of the nursing staff including age, gen-der, marital status, years of experience, type of employment, and educational level weredocumented according to the departments of human resources of the two hospitals.

(2) General principles of nursing documentation: Checklists were designed to assess principles ofnursing documentation in both paper-based and electronic systems considering the standardsof documentation and recording; 12 items for written records and 10 items for vocal-electronicrecords were predicted. These items included registration of patient’s identification and diagnosis,nurse’s name and signature, proper use of medical acronyms, and presence of a clear finalstatement. General coherency and comprehensibility of the records regarding the quality ofvoice recording, clear handwriting, and correction of mistaken entries were also considered inthe checklist.To design the checklists, we referred to the questionnaire utilized by Sattarzadeh et al. as a qualityassessment of nursing documentation in surgical wards (36), the standard manuals of the IranianNursing Council Annual Proclamation on Policy (37), and procedures in nursing (38).Marked items (yes/no answers) on the checklist for each evaluated record were assigned scores; 1for “yes” and 0 for “no” answers. The total scores were calculated from the sum of these points interms of percent.

(3) Quality assessment of nursing records: Priorities in nursing documentation for surgical wardshave been previously introduced in other studies (36). Based on previous research worksand expert consultation, a checklist was compiled comprising 17 items and 24 subitems infour stages of patient admission, preoperative care, postoperative care, and discharge.Records were checked for each item and subitem as: “registered,” “not registered,” “incom-plete,” or “not indicated for case.” Items would then be scored (2 for registered items, 1 forincomplete records, and 0 for unregistered items), and those “not indicated for case” wereomitted. The total scores were calculated based on the sum of all the item scores in terms ofpercent. In order to minimize confounder effects, checklists were completed by trainednurses who were unaware of the objectives of the study.

To check for content validity, the checklists were evaluated and completed by experts in the field,and for reliability measures, Pearson correlation coefficient was calculated (r = 0.99). Parts of thechecklist were identical to the work of Sattarzadeh et al (36). Acquired data were entered into andanalyzed using SPSS version 16. Comparisons were made using chi-square and independent andpaired t-tests for inter- and intra-hospital comparisons for documentation measurements before andafter the implementation of the electronic system. The level of significance was considered to be 0.05.

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Results

In total, 120 documented patient records were investigated in the two surgical wards. Analysis ofintra-hospital variables using paired t-tests showed that the quality of nursing documentationhad significantly changed in 2012 after the implementation of the vocal-electronic system inHasheminejad Hospital (case) (p < 0.001), while no significant change was reported in FiroozgarHospital (control) compared to 2008 (p > 0.05). Inter-hospital comparisons indicated that thetwo wards were significantly different regarding the quality of documentation in both 2008 and2012 (p < 0.001).

Hospital setting and nursing staff

To control for probable confounding effects of the current and previous, demographic and employ-ment features of the nursing staff in both hospitals were evaluated. Findings were compared usingindependent t-test and chi-square test. Data analysis indicated that the two hospitals had nosignificant differences regarding nursing staff (Table 1).

General principles of nursing documentation

Sixty random patient records from 2008 and 2012 were evaluated using the 12-item checklist in thetwo hospitals. In the year 2008, most patient records in both hospitals had no nurse signatures at theend, and unnecessary space between different report paragraphs was reported in many files(Hasheminejad: 96.6%, 60%; Firoozgar: 76.6%, 83.3%). On the contrary, voice records from 2012in Hasheminejad Hospital were compatible with the defined standards (Table 2).

The mean scores and percentages regarding the general principles of documentation had nosignificant difference in the paper-based system in the two hospitals (p = 0.88). The presented dataalso showed that after the implementation of the vocal-electronic system in the index setting, the twohospitals had almost significantly different scores in 2012 (p = 0.056) (Table 3). The total scoresgiven to the two hospitals for general principles of documentation (both paper-based and vocal-electronic system) are indicated in Tables 4 and 5.

Quality assessment of nursing records

To assess the quality of nursing records in the two hospitals, scores were calculated from thesum of points acquired in each of the four stages of patient care: admission, pre- and post-operative, and discharge. The following discrepancies were detected between the two hospitalsin 2008 before the implementation of the vocal-electronic system: pre- and post-operative

Table 1. Demographic and employment characteristics of the nursing personnel in Hasheminejad Hospital and Firoozgar Hospital(years 2008 and 2012).

Variable

Hasheminejad Hospital Firoozgar Hospital p value

2008 2012 2008 2012 2008 2012

Age* 26.83 ± 2.22 26.89 ± 3.48 27.33 ± 3.67 29.09 ± 3.5 p = 0.771α p = 0.178α

Experience (months) 21 ± 7.34 39.67 ± 28.19 55.67 ± 57.42 30 ± 16.86 p = 0.17 p = 0.354Pre-official 1(16.7%) 2(22.2%) 4(44.4%) 7(63.6%) p = 0.381β p = 0.179β

Type of employment Socialservice

0(0%) 4(44.4%) 2(22.2%) 2(18.2%)

Contract 3(50%) 1(11.1%) 2(22.2%) 2(18.2%)Official 2(33.3%) 2(22.2%) 1(11.1%) 0(0%)

*Gender and level of education were primarily matched between the hospitals.αIndependent t-test has been performed.βChi-square test has been performed.

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Table 2. Comparison of nursing documentation scores before and after the implementation of electronic systems in HasheminejadHospital and Firoozgar Hospital (intra-hospital) in 2008 and 2012.

Item

Hasheminejad Hospital, n = 30

p value

Firoozgar Hospital, n = 30

p value

Before (2008) After (2012) Before (2008) After (2012)

Mean + SDScore(%) Mean + SD

Score(%) Mean + SD

Score(%) Mean + SD

Score(%)

Principles ofdocumentation

9.58 + 0.87 81.11 9.63 + 0.72 96.33 p = 0.025* 9.70 + 0.95 80.83 9.10 + 1.03 75.83 p = 0.023

Admissiondocumentation

13.25 + 2.39 73.61 15.20 + 1.55 71 p < 0.001 2.99 + 1.05 16.59 3.57 + 2.90 19.81 p = 0.3

Preoperativedocumentation

14.84 + 1.72 61.84 16.34 + 2.73 68.09 p = 0.014 21.11 + 3.16 46.69 11.28 + 2.70 46.98 p = 0.92

Postoperativedocumentation

22.21 + 2.94 44.41 30.76 + 5.45 61.5 p < 0.001 25.00 + 2.78 49.99 24.81 + 4.01 49.61 p = 0.831

Dischargedocumentation

1.95 + 1.74 19.5 3.70 + 1.93 37 p = 0.001 0.73 + 1.14 7.33 1.49 + 1.24 14.91 p = 0.017

*Level of significance: p < 0.05.

Table 3. Comparison of nursing documentation scores before and after the implementation of electronic systems betweenHasheminejad Hospital and Firoozgar Hospital (inter-hospital) in 2008 and 2012.

Item

Before the implementation of electronicsystems (paper-based)

p value

After the implementation of electronicsystems

p value

Hasheminejadn = 30 (paper)

Firoozgarn = 30 (paper)

Hasheminejadn = 30 (electronic)

Firoozgarn = 30 (paper)

Mean + SDScore(%) Mean + SD

Score(%) Mean + SD

Score(%) Mean + SD

Score(%)

Principles ofdocumentation

9.58 + 0.87 81.11 9.70 + 0.95 80.83 p = 0.888* 9.63 + 0.72 96.33 9.10 + 1.03 75.83 p = 0.056

Admissiondocumentation

13.25 + 2.39 73.61 2.99 + 1.05 16.59 p < 0.001 15.20 + 1.55 71 3.57 + 2.90 19.81 p < 0.001

Preoperativedocumentation

14.84 + 1.72 61.84 21.11 + 3.16 46.69 p < 0.001 16.34 + 2.73 68.09 11.28 + 2.70 46.98 p < 0.001

Postoperativedocumentation

22.21 + 2.94 44.41 25.00 + 2/78 49.99 p < 0.001 30.76 + 5.45 61.5 24.81 + 4.01 49.61 p < 0.001

Dischargedocumentation

1.95 + 1.74 19.5 0.73 + 1/14 7.33 p = 0.002 3.70 + 1.93 37 1.49 + 1.24 14.91 p = 0.002

*Level of significance: p < 0.05.

Table 4. Measuring instrument for general principles of paper-based nursing documentation.

Measurement instrument (2-point scale)

Principles of nursing documentation in paper-based system Yes (1) No (0)1. Presence of complete patient identification at the top2. Use of black or blue pen3. Date, time, and shift registration4. Clear and legible records5. The absence of different handwritings in records6. Use of internationally approved abbreviations7. Unnecessary space between different report paragraphs8. Correcting errors with a defined line and “Error” phrase9. Considering priority in records

10. Registration of the name of responsible nurse in the end of records11. Presence of final nurse signatures12. Close the end of the records12 Items, maximum score = 12

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records had better mean scores in Firoozgar Hospital (p < 0.001), while admission anddischarge records showed higher scores in Hasheminejad Hospital (p < 0.001, p = 0.002).After the implementation of the vocal-electronic system in Hasheminejad Hospital, the qualityof patient records were significantly higher in comparison with the 2008 records; and also whencompared to the present paper-based system in Firoozgar Hospital. In Tables 2 and 3, intra-and inter-hospital comparisons before and after the implementation of the vocal-electronicsystems are shown in detail (2008 vs. 2012).

Discussion

The present study aimed to evaluate and compare the quality of nursing documentation in a newvocal-electronic system with that in the traditional paper-based system for the first time. The mainfindings indicate that both quality and comprehensiveness of nursing records in the vocal-electronicsystem are improved compared to the traditional paper-based methods. Several previous studieshave demonstrated that EHR systems can enhance the quality of nursing documentation; Boltonet al. found that EHR technology in nursing documentation can save time while increasing safetyand quality of patient care (15,25,39). Health-care personnel have also shown to be more convenientin utilization of electronic records, and these documents have been more legible, complete, andaccurate (16,40).

From a managerial perspective and in agreement with the findings of our study, Jang et al. foundthat the use of EHR systems in documentation can be helpful in the establishment of a reliable andall-inclusive database (39) by potentially reducing the rate of medical errors and increasing patientsafety (41). Available literature also underscores another advantage of electronic nursing documen-tation, e.g., simplicity of use and access for all the disciplines involved in a health-care setting(16,42,43). We believe that our findings highlight the important role of technology in modernmanagement systems of Iran, which could be beneficial if considered in other local health-caresettings.

Despite the enhancement of the process of documentation, Gunninberg et al. suggest that thereare shortcomings in the content of EHRs that limit the ability to review nursing procedures andperformance data (44). Another study has shown that nurses concern about the implementation ofEHR documentation and hence the time spent on the process of recording decreases the availabletime for procedures of direct patient care. These findings led to the conclusion that there were nohelpful changes in patient-care procedures, workflow, and the time spent on documentation, andconsequently no changes in quality of documentation (45). Moreover, several studies have shownthat the speed, accessibility, location, and consistency of the computer and electronically establishedprograms may also adversely affect the documentation process (46–49). The findings of our studyhave shown significant improvements in nurse scores regarding the general principles of nursing

Table 5. Measuring instrument for general principles of vocal-electronic nursing documentation.

Measurement instrument (2-point scale)

Principles of nursing documentation in vocal-electronic system Yes (1) No (0)1. Mentioning patient identification in the beginning2. Mentioning the ID of responsible nurse3. Mentioning date, time, and report shift4. Acceptable voice-record quality5. Non similar voices in one record6. Use of internationally approve abbreviations7. Continuity in voice record8. Use of “mistaken entry” phrase for errors in records9. Considering priority in records10. Identifying the end of the records10 Items, maximum score = 10

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documentation. These standard principles are defined to help with integrity and completeness ofrecords; therefore, we suggest that the vocal system can be of prominent help in similar health-caresettings where other electronic documentation systems are in use.

A study in Iran on nursing documentation with an intra-hospital computer network hasemphasized the significance of EHRs in better documentation and patient care. Although thestudy was conducted in a critical care unit and the Hospital Information System (HIS) wasevaluated as the framework for documentation, we propose that the results are in line with ourfindings (50). We believe that the findings of both studies emphasize the demands of other localhospitals for changes in documentation systems with the aid of new technologies. However, theprerequisites of the introduction and implementation of these systems should not beoverlooked.

In assessment of the quality of proper nursing documentation, we found that discharge noteswere among the most incomplete parts of patient records. Other studies also suggest that nurses donot usually incorporate a complete account of a patients’ residual problems in discharge notes, andover 90% of discharge notes have been either incomplete or missing (51–53).

The effects of intra-hospital training programs on the quality of documentation should also beconsidered in interpretation of the findings of this study. Training sessions were scheduledseasonally in Firoozgar Hospital, while monthly sessions were held in Hasheminejad Hospital.As evidence confirms, training programs (i.e., interventions to improve nursing discharge notes)can influence nursing skills in different aspects of care including documentation (54,55). Thecontradictory findings in the studies conducted in Iran (12,56) highlight the importance ofcollecting a more comprehensive evaluation of the current documentation system to aid us inthe development of effective interventions and probably implementation of electronic systems inmore settings.

Other than continuous nursing education, organizational, legal, functional, and motivationalfactors are crucial elements to be addressed when implementing a new documentation system ina health-care setting (56,57,58). The two hospitals evaluated in the present study, except fordifferences in documentation systems, can be different with regard to organizational and manage-rial factors, which may potentially affect quality of nursing documentation; however, we tried tominimize these differences by the selection of academic centers governed by the same medicalschool. A variety of factors have been recognized for consideration in evaluation of documenta-tion systems including admission site, structure of patient care, organizational factors, commu-nication with different health-care professionals, user and patient satisfaction, and type of disease(55). These findings make us aware of the need for several policy changes covering all proceduresfrom implementation to practice in clinical settings (59). Although vocal-electronic systemsresulted in improvements in nursing documentation, we believe that it is beneficial to haveclear principles and legislative considerations. Other potential documentation systems, includingtheir impact on quality of nursing care, and legal barriers need to be further investigated to assisthealth policy makers.

Limitations

The study was confined to one index hospital as the only center officially using a vocal-electronicsystem. The authors tried to eliminate confounder effects by selecting similar wards and checking forbasic nursing staff and documentation principles in the two hospitals. The inherent effects ofdifferences in the content of training programs should also be considered when interpreting thechanges observed in nursing documentation in the vocal-electronic system compared to the paper-based system.

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Conclusions

We found that vocal-electronic nursing documentation can lead to improvements in the quality ofnursing records, but considering the existing facilities in our hospitals, other major changes seemessential for the implementation of such a system on a larger scale. We also suggest that standardi-zation of vocal-electronic nursing documentation in the health-care organization is required toenable more competent exchange of data between patients and health-care providers. A standardapproach is also essential for nursing staff to involve them in the process of electronic nursingdocumentation.

Acknowledgment

The authors would like to thank the personnel of Hasheminejad Hospital and Firoozgar Hospital for their kindcooperation. We are also grateful to the staff of the Faculty of Nursing and Midwifery of TUMS for their help andsupport.

Funding

The study was financially supported by the Tehran University of Medical Sciences.

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