Applicability of electronic health records in the hospital Nursing Process: a scoping review

电子健康记录在医院护理过程中的适用性:范围界定综述

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Abstract

OBJECTIVES: to synthesize scientific evidence on the applicability of Electronic Health Records in the Nursing Process in hospitals. METHODS: a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with searches in six electronic databases, restricted to publications in Portuguese, English, and Spanish from 2019 to 2024. RESULTS: a total of 2,789 results were found, with 33 articles included in the search and classified into four thematic categories. The countries with the most publications include Brazil, the United States, and China, with a focus on 2021. CONCLUSIONS: hospital Nursing Process records are crucial for verifying care and managing risks, improving quality and patient safety. Implementing Electronic Health Records optimizes work and reduces costs, alleviating staff burden. In addition to supporting clinical decision-making, these records also generate secondary data that drives scientific research.

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