gms | German Medical Science

Background and state of (inter)national research: The introduction of the electronic health record has positive as well as negative implications for daily routines in hospitals. On the one hand, there is evidence for several aspects of the EHR that may lead to higher staff burden [1] which is contrasted with the chance of improved coordination of care and therefore high quality of care [2] on the other hand. However, the impact of the electronic health record on actual documentation is often neglected.

Research question and objective: How does inpatient documentation change by introducing an electronic health record? The study reviews the comparison of handwritten and electronic documentation during the transition from paper-based to electronic health records in hospitals.

Methods: A systematic review was conducted searching the databases PubMed (incl. PubMed, PubMed Central, MEDLINE), Web of Science Core Collection, CINAHL and PDQ Evidence. All peer-reviewed studies were included that compare the documentation in health records during the transition from paper-based to electronic health records in hospitals from 2010–2020.

Results: Of 264 studies, 19 met the inclusion criteria. Preliminary sighting of the results shows outcomes often focussing on completeness of documentation or clinical guideline adherence. Although the data situation is heterogeneous, it seems the electronic health record improves documentation compared to paper-based records.

Discussion: Despite the existence of instruments for assessing aspects of documentation, e.g. the quality of documentation, most included studies did not use those. In addition to that the circumstance of considering various use cases makes the results of the different studies hard to compare.

Practical implications: During the implementation process from paper-based to electronic health records, the change in documentation should be regularly monitored with assessment instruments. This way, weak points could easily be identified, and the interface of the electronic health record could be adjusted.