Nursing documentation - paper vs. electronic documentation

Background: The introduction of electronic nursing documentation, involving the application of classification systems such as NANDA and NIC, raised hopes of a change in quality of the documentation. Method: A retrospective descriptive document analysis prior to and after introduction of the electronic nursing module in the electronic patient journal by means of using a Norwegian version of the Swedish mapping instrument for nursing journals Cat-ch-ing, supplemented with two ethical questions. Study group: Paper-based (n = 30) and electronic nursing records (n = 30) from discharged geropsychiatric patients. Results: The study shows an improvement, both quantitative and qualitative, in the electronic nursing documentation. Conclusion: There is a need for more education to meet the requirements of the law, as well as further development of the electronic version of the documentation module with respect to the classification system.