Abstract
Electronic Health Records (EHR) have been adopted to improve the quality of care. Despite the growing use of health information technology, nursing documentation remains a challenge. In Tunisia, the implementation of the Electronic Medical Record (EMR) system is gaining momentum as part of national initiatives to modernize healthcare. However, nursing documentation is still largely paper-based, and no studies in Tunisia have adressed this topic. This research aims to assess the effect of the Electronic Nursing Record (ENR) on the quality and safety of care indicators (QSCI). This is an interventional study structured in four phases: development, pre-implementation, implementation, and evaluation, integrating the principles of the 'Standards for Reporting Implementation Studies' (StaRI). A list of QSCI was defined and validated through a literature review and Delphi consensus. The impact of the ENR on these indicators was evaluated in a Tunisian university hospital through a quasi-experimental study. Indicators were measured before ENR, one month after, and six months after. Data analyses was conducted using SPSS with statistical tests. Initially, the study led to the identification and validation of seventeen QSCI. Subsequently, a quasi-experimental study was conducted to evaluate the impact of ENR implementation on these indicators. The results revealed a significant improvement in the intervention group (using ENR), particularly in the traceability of vital signs (p < 10⁻(3)) and infusion administration (p = 0.027). Conversely, the control group (using paper-based documentation) performed better in terms of traceability of inter-team handovers (95.1% compared to 71.9% for the intervention group). The electronic documentation system is seen as a major transformation in healthcare in many hospitals worldwide. Moreover, electronic nursing documentation is crucial for patient safety. Its implementation in our hospital revealed a positive impact of the ENR on certain aspects of care quality while highlighting gaps in inter-team handovers.