{"paper_id":"47eb02b8-22cb-401b-b856-10844cf74dae","body_text":"Nursing Documentation Transformation through AI-Enhanced Electronic Health Records and Standardized Terminologies: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Nursing Documentation Transformation through AI-Enhanced Electronic Health Records and Standardized Terminologies: A Systematic Review Kori Limbong, Moses Glorino Rumambo Pandin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7693354/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Nursing documentation plays a pivotal role in ensuring continuity, quality, and safety of care. The integration of electronic health records (EHRs) has facilitated more accurate and accessible records; however, challenges remain regarding documentation burden, workflow interruptions, and limited patient participation. Objective: This systematic review aimed to identify, evaluate, and synthesize recent evidence on facilitators, barriers, and innovations in electronic nursing documentation, with a particular focus on standardized terminologies and emerging artificial intelligence (AI) applications. Methods: Following PRISMA 2020 guidelines, a comprehensive search of PubMed, Scopus, Web of Science, and CINAHL retrieved 215 records. After duplicate removal and screening, 8 empirical studies published between 2021 and 2025 met the inclusion criteria. Data were extracted and synthesized narratively due to methodological heterogeneity. Results: Findings highlight that system usability, organizational support, and adequate training are key enablers of EHR adoption, while infrastructural gaps and technostress pose barriers. Standardized terminologies, including ICNP and the Omaha System, improved documentation consistency and interoperability. Patient participation remained limited, though digital literacy and trust were important factors. Emerging evidence indicates that AI-assisted tools can reduce documentation time, improve accuracy, and alleviate workload. Conclusion: EHRs hold transformative potential for nursing documentation, yet their success depends on workflow- aligned system design, validated intelligent technologies, and inclusive approaches that enhance both professional practice and patient engagement. Nursing Medical Informatics Nursing Documentation Transformation AI-EHR Standardized Terminologies Figures Figure 1 INTRODUCTION Nursing documentation is a cornerstone of professional practice, ensuring continuity, safety, and quality of care. The transition to electronic health records (EHRs) has created new opportunities for improving communication, reducing medical errors, and supporting clinical decision-making(Shafiee et al., 2022)(Douma et al., 2024). Nevertheless, nurses worldwide continue to face barriers such as workflow disruptions, usability challenges, and increased administrative burden(Alkasasbeh et al., 2025) (Asiri, 2024). Global evidence highlights these challenges. An OECD survey across 27 countries reported that while most nations have adopted EHR systems, only 15 maintain unified national records, reflecting ongoing gaps in interoperability and consistency(Slawomirski et al., 2023) In practice, nurses’ workload is heavily affected: documentation tasks, particularly flowsheets, occupy nearly one-third of a 12-hour shift, signaling significant time consumption(Jacques et al., 2025) Conversely, studies in Norway show that incorporating standardized nursing care plans into EHRs enhances consistency and supports more structured care processes(Laukvik et al., 2024). At the same time, empirical studies underline that successful adoption depends on multiple factors. In Saudi Arabia and Jordan, organizational support, technical infrastructure, and adequate training were key facilitators, while limited time and system inefficiencies acted as barriers (Asiri, 2024) (Alkasasbeh et al., 2025). Furthermore, digital documentation is reshaping professional roles. Studies in Denmark report that digital health documentation transforms communication and professional identity in primary care (Duval Jensen et al., 2023) while community nurses in the Netherlands highlight the limited yet valuable involvement of patients in documentation processes(De Groot et al., 2021). Collectively, these findings underscore both the potential and the complexity of digital nursing documentation, with emerging technologies such as AI promising to reduce workload and improve accuracy(H. Ju et al., 2025). Given these diverse perspectives, a systematic review is needed to synthesize evidence on facilitators, barriers, and innovations in electronic nursing documentation, providing insights to guide implementation strategies that balance efficiency, quality, and patient-centeredness. METHODS Study Design This study applied a systematic review design based on the PRISMA 2020 guidelines. The design was chosen to ensure that the process of identifying, evaluating, and synthesizing empirical evidence regarding nursing documentation was conducted transparently, rigorously, and in a reproducible manner. The review specifically focused on the integration of electronic health records (EHRs), the application of standardized nursing terminologies, and the use of artificial intelligence (AI) in documentation practices. Through this design, the review sought to capture not only the effectiveness of such interventions but also the barriers and facilitators influencing their adoption in diverse healthcare contexts (See Fig. 1 ). Inclusion and Exclusion Criteria The inclusion and exclusion criteria were established before the review process. Studies were eligible for inclusion if they were published between January 2021 and September 2025, focused explicitly on nursing documentation, electronic health records, standardized terminologies, or AI-based applications, and employed empirical research designs, whether quantitative, qualitative, or mixed methods. Only full-text articles published in English and reporting outcomes related to documentation quality, usability, adoption, patient safety, or professional practice were considered. Conversely, studies were excluded if they dealt with general medical documentation without relevance to nursing, were reviews, editorials, commentaries, conference abstracts, or grey literature, or if they lacked sufficient methodological rigor or were inaccessible in full text. These criteria ensured that only high-quality and contextually relevant evidence was included in the synthesis. Searching Strategy A comprehensive searching strategy was implemented across four major electronic databases: PubMed, Scopus, Web of Science, and CINAHL. The search was conducted on September 11, 2025, using carefully constructed combinations of keywords and Boolean operators tailored to the indexing system of each database. Search terms included variations of “nursing documentation,” “electronic nursing record,” “electronic health record,” “standardized terminologies” such as ICNP, Omaha System, or NANDA–NIC–NOC, and technology-related terms such as “artificial intelligence” or “machine learning.” In addition to the database search, reference lists of the included articles were manually screened to identify additional relevant studies, thereby strengthening the comprehensiveness of the review process. Procedure of Data Extraction The procedure of data extraction was carried out by two independent reviewers using a structured data extraction form. The extracted information encompassed bibliographic details of each study, the design and characteristics of the sample, the type of intervention or thematic focus, such as EHR systems, standardized terminology integration, or AI-based documentation tools, as well as the key outcomes, including usability, efficiency, accuracy, patient safety, and participation. Each reviewer worked independently to reduce bias, and any discrepancies were resolved through discussion. In cases where disagreements could not be resolved, a third reviewer was consulted to reach a consensus. Given the heterogeneity in study designs and outcomes, the data were synthesized narratively rather than through quantitative meta-analysis. This descriptive synthesis allowed for a nuanced understanding of the diverse methodological approaches and findings, providing a holistic view of the current evidence landscape in nursing documentation research. RESULTS The results of the research articles on transforming nursing documentation: electronic health records, standardized terminologies, and emerging AI applications are presented in Table 1 . Table 1 The research articles transforming nursing documentation: electronic health records, standardized terminologies, and emerging AI applications No Title, Author, Years Method Result 1 Factors Influencing Electronic Health Record Workflow Integration among Nurses in Saudi Arabia(Asiri, 2024 ) A cross-sectional survey was conducted with 482 nurses to assess factors influencing EHR integration. Variables included usability, training, and managerial support; data were collected through questionnaires and analyzed using logistic regression The results indicated that system usability, adequate training, and managerial support enhanced EHR adoption, while limited infrastructure acted as a barrier. Younger nurses were found to adopt EHRs more quickly than senior nurses. 2 Developmentand Evaluationofan Electronic Nursing Documentation System(Shafieeet al., 2022) A mixed-methods study combining observation, interviews, and system evaluation among inpatient nurses focused on accuracy, efficiency, and satisfaction. Thematic analysis and comparative tests revealed that documentation was more accurate, less duplicative, and more satisfactory The new system reduced duplication of records, improved the accuracy of clinical data, and facilitated access to patient information. Nurses reported higher satisfaction due to well- digitalized workflows. 3 Effect of a Practice- Oriented EMR Education Program for New Nurses(J. K. Ju & Jeong, 2025 ) A quasi-experimental design involving 60 novice nurses (30 intervention, 30 control) measured self-efficacy and EMR skills using questionnaires and system logs, with data analyzed using t-tests and ANCOVA Findings showed significant improvements in self-efficacy and documentation efficiency in the intervention group compared with controls 4 Factors Influencing the Utilization and Adoptionof Electronic Health Records among Nurses in Jordanian Hospitals(Alkasasb eh et al., 2025) A cross-sectional survey with 373 nurses assessed system quality, information quality, and self-efficacy using Likert-scale questionnaires, analyzed with multiple regression. Results showed positive associations among these factors, while age and experience had moderate effects 5 Impactof Implementing Electronic Nursing A pre–post quasi-experiment with 38 nurses and 472 infusion patients measured quality and safety indicators (medication errors, The implementation of ENRs improvedmedication traceability, reduced infusion Records on Quality andSafety Indicatorsin Care(Douma et al., 2024 ) traceability, and handover) using medical audits and checklists, analyzed descriptively and with chi-square tests. errors, and increased proceduralcompliance. However,inter-shift handover remained weak due toinsufficient synchronization of nursing data. 6 How Digital Health Documentation Transforms Professional Practices in Primary Healthcarein Denmark(Duval Jensen et al., 2023 ) A document analysis design was employed using the WPR (What’s the Problem Represented to be?) approach. The sample consisted of policy documents and primary care practice records. The variable analyzed was the representation of problems within digital documentation. The analysis was conducted through a critical discourse approach. Digital documentation has transformed nursing practice by enhancing transparency and organizational control; however, it also poses risks of fragmented responsibility and reducedprofessional autonomy 7 Patient Participation inElectronic Nursing Documentation(De Groot et al., 2021 ) A qualitative study with a descriptive design was conducted. The sample consisted of 19 community nurses who participated in semi- structured interviews. Variables included patient participation in documentation, related challenges, and applied strategies. Data were analyzed using reflexive thematic analysis Patient participation was influenced by medical condition,trustin documentation, and digital skills. Other barriers included time constraints and technical issues, leading nurses to frequently rely on verbal communicationbefore recording documentation. 8 Implementing Oncologic Nursing Care Plans in EHR withTwo Taxonomies(Togni et al., 2025 ) A participatory action research (PAR) design was implemented in hematology and oncology units. The sample consisted of oncology nursing teams who acted as co- researchers. The main variable was the implementation of care plans based on standardized terminologies, namely ICNP compared with NANDA–NIC–NOC. Instruments included focus groups, preference surveys, and system pilot testing. Data were analyzed using descriptive quantitative methods and qualitative analysis through focus group discussions. Nurses preferred the ICNP terminology due to its flexibility, and end-user involvementreduced resistance while enhancing the quality of documentation DISCUSSION The integration of Electronic Health Records (EHRs) into nursing practice has shown significant benefits, particularly in improving documentation quality, patient safety, and service efficiency. Several studies indicate that system quality and usability are central determinants of EHR adoption. For instance, a survey in Jordan found that system quality, information quality, and nurses’ self-efficacy were positively associated with EHR utilization(Alkasasbeh et al., 2025 ). Similar findings in Saudi Arabia highlighted the importance of organizational support, adequate training, and usability for successful workflow integration, while infrastructural limitations remained a barrier(Asiri, 2024 ). Despite these advantages, challenges persist. The documentation burden has been frequently cited as a source of dissatisfaction and stress among nurses. Furthermore, qualitative research has described how technostress emerges when EMR tasks are poorly aligned with clinical workflows, despite the acknowledged benefits of improved safety and data access(Provenzano et al., 2024 ). Work interruptions during EHR use further exacerbate mental workload. Observational research has shown that frequent interruptions during documentation tasks increase cognitive load and negatively impact performance(Shan et al., 2023 ) Addressing such challenges, interventions like EHR-embedded care pathways have demonstrated measurable benefits. A recent implementation study showed that embedding structured pathways in oncology consultations reduced EHR task time by 27% during initial visits and improved clinician perceptions of usability, though less impact was observed during follow-ups (Ebbers et al., 2024 ). These findings highlight the value of aligning system design with workflow complexity. Patient participation represents another underexplored opportunity. Although digital portals provide potential for patient involvement, studies suggest that participation remains limited by digital literacy, time constraints, and technical issues. A qualitative study in the Netherlands found that nurses often relied on verbal discussions with patients before documenting, highlighting gaps in inclusive system design(de Groot et al., 2022 ). The use of standardized nursing terminologies has been strongly supported as a means of ensuring consistency and interoperability. A comparative study in the U.S. found that the Omaha System enabled more comprehensive documentation of social and behavioral determinants of health compared with free-text (Monsen et al., 2019). Similarly, oncology nurses in Italy favored ICNP for its flexibility and compatibility with SNOMED-CT, underlining the importance of involving end-users in system development(Togni et al., 2025 ). Emerging evidence suggests that artificial intelligence (AI) can offer meaningful solutions to the challenges of nursing documentation. A recent study evaluated a generative AI–based recommendation system designed to support nursing diagnosis and documentation(H. Ju et al., 2025b ). The system significantly reduced the time required for documentation, while also improving the accuracy and usability of nursing records. These findings indicate that AI tools, when properly integrated into electronic health record systems, can alleviate the administrative burden often reported by nurses and enhance the overall quality of documentation. Importantly, such interventions highlight the potential of combining advanced technologies with standardized nursing terminologies and workflow-centered design, ensuring that digital solutions are not only efficient but also clinically relevant and sustainable in everyday practice. This review highlights the novelty of examining electronic health record (EHR) use in nursing through a socio- technical perspective, emphasizing that system usability, organizational support, and technostress are closely interrelated; that structured care pathways can enhance workflow efficiency; that patient participation remains constrained by design and digital literacy barriers; and that integrating standardized nursing terminologies with artificial intelligence (AI) offers next-generation solutions to improve accuracy and reduce documentation burden. However, several limitations should be acknowledged, including methodological heterogeneity, geographic concentration of studies, reliance on predominantly short-term evidence, and the early stage of AI applications, in addition to potential publication bias. These findings underscore both the potential and complexity of digital nursing documentation while highlighting critical gaps that future research must address. From a practical standpoint, the results emphasize the need for practice-oriented training programs, workflow-aligned system design, and the integration of validated intelligent technologies to reduce administrative burden. Furthermore, strengthening patient participation through more inclusive digital solutions will ensure that EHRs function not merely as administrative tools but as instruments to enhance care quality, safety, and patient engagement. CONCLUSION This systematic review demonstrates that the integration of electronic health records (EHRs) into nursing practice holds substantial potential for improving documentation quality, efficiency, and patient safety. Evidence highlights that successful adoption requires not only robust technical systems but also organizational support, training, and alignment with clinical workflows. While standardized nursing terminologies and structured care pathways contribute to greater consistency and interoperability, challenges such as documentation burden, technostress, and limited patient participation remain significant barriers. Emerging technologies, particularly artificial intelligence, offer promising avenues to alleviate workload and enhance accuracy; however, their application is still at an early stage and requires rigorous validation. Future research should therefore focus on long-term evaluations, inclusive design strategies, and context-specific implementations to ensure that digital nursing documentation evolves as both a clinically effective and user-centered innovation. Declarations Funding Statement: This study received no external funding. Conflict of Interest Statement: The authors declare no conflicts of interest. Ethics Statement: This study is a systematic review and did not involve human participants; therefore, ethical approval was not required. References Alkasasbeh, A. M., Jarrah, S. S., Alhusamiah, B. K., & Tarawneh, F. S. (2025). Factors Influencing the Utilization and Adoption of Electronic Health Records among Nurses in Jordanian Hospitals. Jordan Journal of Nursing Research , 4 (1), 68–80. https://doi.org/10.14525/JJNR.v4i1.08 Asiri, S. (2024). Factors Influencing Electronic Health Record Workflow Integration Among Nurses in Saudi Arabia: Cross-Sectional Study. SAGE Open Nursing , 10 . https://doi.org/10.1177/23779608241260547 de Groot, K., Douma, J., Paans, W., & Francké, A. L. (2022). Patient participation in electronic nursing documentation: An interview study among home-care patients. Health Expectations , 25 (4), 1508–1516. https://doi.org/10.1111/hex.13492 De Groot, K., Sneep, E. B., Paans, W., & Francke, A. L. (2021). Patient participation in electronic nursing documentation: an interview study among community nurses. BMC Nursing , 20 (1). https://doi.org/10.1186/s12912-021-00590-7 Douma, M. C., Rejeb, M. Ben, Zardoub, N., Braham, A., Chouchene, H., Bouallegue, O., & Latiri, H. S. (2024). Impact of Implementing Electronic Nursing Records on Quality and Safety Indicators in Care. Libyan Journal of Medicine , 19 (1). https://doi.org/10.1080/19932820.2024.2421625 Duval Jensen, J., Ledderer, L., & Beedholm, K. (2023). How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis. Nursing Inquiry , 30 (1). https://doi.org/10.1111/nin.12499 Ebbers, T., Takes, R. P., Smeele, L. E., Kool, R. B., van den Broek, G. B., & Dirven, R. (2024). The implementation of a multidisciplinary, electronic health record embedded care pathway to improve structured data recording and decrease electronic health record burden. International Journal of Medical Informatics , 184 , 105344. https://doi.org/10.1016/j.ijmedinf.2024.105344 Jacques, D., Will, J., Dauterman, D., Zavotsky, K. E., Delmore, B., Doty, G. R., O’Brien, K., & Groom, L. (2025). Evaluating Nurses’ Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis. JMIR Nursing , 8 (1). https://doi.org/10.2196/69651 Ju, H., Park, M., Jeong, H., Lee, Y., Kim, H., Seong, M., & Lee, D. (2025a). Generative AI-Based Nursing Diagnosis and Documentation Recommendation Using Virtual Patient Electronic Nursing Record Data. Healthcare Informatics Research , 31 (2), 156–165. https://doi.org/10.4258/hir.2025.31.2.156 Ju, H., Park, M., Jeong, H., Lee, Y., Kim, H., Seong, M., & Lee, D. (2025b). Generative AI-Based Nursing Diagnosis and Documentation Recommendation Using Virtual Patient Electronic Nursing Record Data. Healthcare Informatics Research , 31 (2), 156–165. https://doi.org/10.4258/hir.2025.31.2.156 Ju, J. K., & Jeong, H. W. (2025). Effect of a Practice-Oriented Electronic Medical Record Education Program for New Nurses. Healthcare (Switzerland) , 13 (4). https://doi.org/10.3390/healthcare13040365 Laukvik, L. B., Lyngstad, M., Rotegård, A. K., & Fossum, M. (2024). Utilizing nursing standards in electronic health records: A descriptive qualitative study. International Journal of Medical Informatics , 184 , 105350. https://doi.org/10.1016/j.ijmedinf.2024.105350 Provenzano, M., Cillara, N., Curcio, F., Pisu, M. O., González, C. I. A., & Jiménez-Herrera, M. F. (2024). Electronic Health Record Adoption and Its Effects on Healthcare Staff: A Qualitative Study of Well-Being and Workplace Stress. International Journal of Environmental Research and Public Health , 21 (11). https://doi.org/10.3390/ijerph21111430 Shafiee, M., Shanbehzadeh, M., Nassari, Z., & Kazemi-Arpanahi, H. (2022). Development and evaluation of an electronic nursing documentation system. BMC Nursing , 21 (1). https://doi.org/10.1186/s12912-021-00790-1 Shan, Y., Shang, J., Yan, Y., & Ye, X. (2023). Workflow interruption and nurses’ mental workload in electronic health record tasks: An observational study. BMC Nursing , 22 (1). https://doi.org/10.1186/s12912-023-01209-9 Slawomirski, L., Lindner, L., Bienassis, K. de, Haywood, P., Hashiguchi, T. C. O., Steentjes, M., & Oderkirk, J. (2023). Progress on implementing and using electronic health record systems . https://doi.org/10.1787/4f4ce846-en Togni, S., Saracino, L., Cieri, M., Bianco, R., Terzoni, S., Giulia, S. M., Zito, E., Lusignani, M., Silvia, P. M., & Depalma, L. (2025). Implementing Oncologic Nursing Care Plans in Electronic Health Records With Two Taxonomies: A Pilot Study. Western Journal of Nursing Research , 47 (3), 159–168. https://doi.org/10.1177/01939459241310402 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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databases.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7693354/v1/fccaa62824c468dca0fd1105.png\"},{\"id\":92054267,\"identity\":\"d9f6b0d7-9d9f-4cce-a8d1-67a0f3e6655d\",\"added_by\":\"auto\",\"created_at\":\"2025-09-24 06:32:35\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":621627,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7693354/v1/b2fde6c5-3acb-4fb4-aea6-61d6c7ad3237.pdf\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003eNursing Documentation Transformation through AI-Enhanced Electronic Health Records and Standardized Terminologies: A Systematic Review\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eNursing documentation is a cornerstone of professional practice, ensuring continuity, safety, and quality of care. The transition to electronic health records (EHRs) has created new opportunities for improving communication, reducing medical errors, and supporting clinical decision-making(Shafiee et al., 2022)(Douma et al., 2024). Nevertheless, nurses worldwide continue to face barriers such as workflow disruptions, usability challenges, and increased administrative burden(Alkasasbeh et al., 2025) (Asiri, 2024).\\u003c/p\\u003e\\n\\u003cp\\u003eGlobal evidence highlights these challenges. An OECD survey across 27 countries reported that while most nations have adopted EHR systems, only 15 maintain unified national records, reflecting ongoing gaps in interoperability and consistency(Slawomirski et al., 2023) In practice, nurses’ workload is heavily affected: documentation tasks, particularly flowsheets, occupy nearly one-third of a 12-hour shift, signaling significant time consumption(Jacques et al., 2025) Conversely, studies in Norway show that incorporating standardized nursing care plans into EHRs enhances consistency and supports more structured care processes(Laukvik et al., 2024).\\u003c/p\\u003e\\n\\u003cp\\u003eAt the same time, empirical studies underline that successful adoption depends on multiple factors. In Saudi Arabia and Jordan, organizational support, technical infrastructure, and adequate training were key facilitators, while limited time and system inefficiencies acted as barriers (Asiri, 2024) (Alkasasbeh et al., 2025).\\u003c/p\\u003e\\n\\u003cp\\u003eFurthermore, digital documentation is reshaping professional roles. Studies in Denmark report that digital health documentation transforms communication and professional identity in primary care (Duval Jensen et al., 2023) while community nurses in the Netherlands highlight the limited yet valuable involvement of patients in documentation processes(De Groot et al., 2021). Collectively, these findings underscore both the potential and the complexity of digital nursing documentation, with emerging technologies such as AI promising to reduce workload and improve accuracy(H. Ju et al., 2025).\\u003c/p\\u003e\\n\\u003cp\\u003eGiven these diverse perspectives, a systematic review is needed to synthesize evidence on facilitators, barriers, and innovations in electronic nursing documentation, providing insights to guide implementation strategies that balance efficiency, quality, and patient-centeredness.\\u003c/p\\u003e\"},{\"header\":\"METHODS\",\"content\":\"\\u003cp\\u003eStudy Design\\u003c/p\\u003e\\u003cp\\u003eThis study applied a systematic review design based on the PRISMA 2020 guidelines. The design was chosen to ensure that the process of identifying, evaluating, and synthesizing empirical evidence regarding nursing documentation was conducted transparently, rigorously, and in a reproducible manner. The review specifically focused on the integration of electronic health records (EHRs), the application of standardized nursing terminologies, and the use of artificial intelligence (AI) in documentation practices. Through this design, the review sought to capture not only the effectiveness of such interventions but also the barriers and facilitators influencing their adoption in diverse healthcare contexts (See Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eInclusion and Exclusion Criteria\\u003c/h3\\u003e\\n\\u003cp\\u003eThe inclusion and exclusion criteria were established before the review process. Studies were eligible for inclusion if they were published between January 2021 and September 2025, focused explicitly on nursing documentation, electronic health records, standardized terminologies, or AI-based applications, and employed empirical research designs, whether quantitative, qualitative, or mixed methods. Only full-text articles published in English and reporting outcomes related to documentation quality, usability, adoption, patient safety, or professional practice were considered. Conversely, studies were excluded if they dealt with general medical documentation without relevance to nursing, were reviews, editorials, commentaries, conference abstracts, or grey literature, or if they lacked sufficient methodological rigor or were inaccessible in full text. These criteria ensured that only high-quality and contextually relevant evidence was included in the synthesis.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eSearching Strategy\\u003c/h2\\u003e\\u003cp\\u003eA comprehensive searching strategy was implemented across four major electronic databases: PubMed, Scopus, Web of Science, and CINAHL. The search was conducted on September 11, 2025, using carefully constructed combinations of keywords and Boolean operators tailored to the indexing system of each database. Search terms included variations of \\u0026ldquo;nursing documentation,\\u0026rdquo; \\u0026ldquo;electronic nursing record,\\u0026rdquo; \\u0026ldquo;electronic health record,\\u0026rdquo; \\u0026ldquo;standardized terminologies\\u0026rdquo; such as ICNP, Omaha System, or NANDA\\u0026ndash;NIC\\u0026ndash;NOC, and technology-related terms such as \\u0026ldquo;artificial intelligence\\u0026rdquo; or \\u0026ldquo;machine learning.\\u0026rdquo; In addition to the database search, reference lists of the included articles were manually screened to identify additional relevant studies, thereby strengthening the comprehensiveness of the review process.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eProcedure of Data Extraction\\u003c/h3\\u003e\\n\\u003cp\\u003eThe procedure of data extraction was carried out by two independent reviewers using a structured data extraction form. The extracted information encompassed bibliographic details of each study, the design and characteristics of the sample, the type of intervention or thematic focus, such as EHR systems, standardized terminology integration, or AI-based documentation tools, as well as the key outcomes, including usability, efficiency, accuracy, patient safety, and participation. Each reviewer worked independently to reduce bias, and any discrepancies were resolved through discussion. In cases where disagreements could not be resolved, a third reviewer was consulted to reach a consensus. Given the heterogeneity in study designs and outcomes, the data were synthesized narratively rather than through quantitative meta-analysis. This descriptive synthesis allowed for a nuanced understanding of the diverse methodological approaches and findings, providing a holistic view of the current evidence landscape in nursing documentation research.\\u003c/p\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eThe results of the research articles on transforming nursing documentation: electronic health records, standardized terminologies, and emerging AI applications are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eThe research articles transforming nursing documentation: electronic health records, standardized terminologies, and emerging AI applications\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eNo\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eTitle, Author, Years\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eMethod\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eResult\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eFactors Influencing Electronic Health Record Workflow Integration among Nurses in Saudi Arabia(Asiri, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA cross-sectional survey was conducted with 482 nurses to assess factors influencing EHR integration. Variables included usability, training, and managerial support; data were collected through questionnaires and analyzed using logistic regression\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eThe results indicated that system usability, adequate training, and managerial support enhanced EHR adoption, while limited infrastructure acted as a barrier. Younger nurses were found to adopt EHRs more\\u003c/p\\u003e\\u003cp\\u003equickly than senior nurses.\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eDevelopmentand Evaluationofan Electronic Nursing Documentation System(Shafieeet al., 2022)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA mixed-methods study combining observation, interviews, and system evaluation among inpatient nurses focused on accuracy, efficiency, and satisfaction. Thematic analysis and comparative tests revealed that documentation was more\\u003c/p\\u003e\\u003cp\\u003eaccurate, less duplicative, and more satisfactory\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eThe new system reduced duplication of records, improved the accuracy of clinical data, and facilitated access to patient information. Nurses reported higher\\u003c/p\\u003e\\u003cp\\u003esatisfaction due to well- digitalized workflows.\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eEffect of a Practice- Oriented EMR Education Program for New Nurses(J.\\u003c/p\\u003e\\u003cp\\u003eK. Ju \\u0026amp; Jeong, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA quasi-experimental design involving 60 novice nurses (30 intervention, 30 control) measured self-efficacy and EMR skills using questionnaires and system logs, with data analyzed using t-tests and ANCOVA\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eFindings showed significant improvements in self-efficacy and documentation efficiency in the intervention group compared with controls\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eFactors Influencing the Utilization and Adoptionof Electronic Health Records among Nurses in Jordanian Hospitals(Alkasasb\\u003c/p\\u003e\\u003cp\\u003eeh et al., 2025)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA cross-sectional survey with 373 nurses assessed system quality, information quality, and self-efficacy using Likert-scale questionnaires, analyzed with multiple regression.\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eResults showed positive associations among these factors, while age and experience had moderate effects\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eImpactof\\u003c/p\\u003e\\u003cp\\u003eImplementing Electronic Nursing\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA pre\\u0026ndash;post quasi-experiment with 38 nurses and 472 infusion patients measured quality and safety indicators (medication errors,\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eThe implementation of ENRs improvedmedication traceability, reduced infusion\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Taba\\\" border=\\\"1\\\"\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eRecords on Quality andSafety\\u003c/p\\u003e\\u003cp\\u003eIndicatorsin Care(Douma et al., \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003etraceability, and handover) using medical audits and checklists, analyzed descriptively and with chi-square tests.\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eerrors, and increased proceduralcompliance.\\u003c/p\\u003e\\u003cp\\u003eHowever,inter-shift handover remained weak due toinsufficient\\u003c/p\\u003e\\u003cp\\u003esynchronization of nursing data.\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e6\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eHow Digital Health Documentation Transforms Professional Practices in Primary Healthcarein Denmark(Duval Jensen et al., \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA document analysis design was employed using the WPR (What\\u0026rsquo;s the Problem Represented to be?) approach. The sample consisted of policy documents and primary care practice records. The variable analyzed was the representation of problems within digital documentation. The analysis was conducted through a critical discourse\\u003c/p\\u003e\\u003cp\\u003eapproach.\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eDigital documentation has transformed nursing practice by enhancing transparency and organizational control; however, it also poses risks of fragmented responsibility and reducedprofessional autonomy\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePatient Participation inElectronic Nursing Documentation(De Groot et al., \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA qualitative study with a descriptive design was conducted. The sample consisted of 19 community nurses who participated in semi- structured interviews. Variables included patient participation in documentation, related challenges, and applied strategies. Data were analyzed using reflexive thematic analysis\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003ePatient participation was influenced by medical condition,trustin documentation, and digital skills. Other barriers included time constraints and technical issues, leading nurses to frequently rely on verbal communicationbefore\\u003c/p\\u003e\\u003cp\\u003erecording documentation.\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eImplementing Oncologic Nursing Care Plans in EHR withTwo\\u003c/p\\u003e\\u003cp\\u003eTaxonomies(Togni et al., \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eA participatory action research (PAR) design was implemented in hematology and oncology units. The sample consisted of oncology nursing teams who acted as co- researchers. The main variable was the implementation of care plans based on standardized terminologies, namely ICNP compared with NANDA\\u0026ndash;NIC\\u0026ndash;NOC. Instruments included focus groups, preference surveys, and system pilot testing. Data were analyzed using descriptive quantitative methods and qualitative analysis through\\u003c/p\\u003e\\u003cp\\u003efocus group discussions.\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eNurses preferred the ICNP terminology due to its flexibility, and end-user involvementreduced resistance while enhancing the quality of documentation\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eThe integration of Electronic Health Records (EHRs) into nursing practice has shown significant benefits, particularly in improving documentation quality, patient safety, and service efficiency. Several studies indicate that system quality and usability are central determinants of EHR adoption. For instance, a survey in Jordan found that system quality, information quality, and nurses\\u0026rsquo; self-efficacy were positively associated with EHR utilization(Alkasasbeh et al., \\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e). Similar findings in Saudi Arabia highlighted the importance of organizational support, adequate training, and usability for successful workflow integration, while infrastructural limitations remained a barrier(Asiri, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eDespite these advantages, challenges persist. The documentation burden has been frequently cited as a source of dissatisfaction and stress among nurses. Furthermore, qualitative research has described how technostress emerges when EMR tasks are poorly aligned with clinical workflows, despite the acknowledged benefits of improved safety and data access(Provenzano et al., \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eWork interruptions during EHR use further exacerbate mental workload. Observational research has shown that frequent interruptions during documentation tasks increase cognitive load and negatively impact performance(Shan et al., \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e) Addressing such challenges, interventions like EHR-embedded care pathways have demonstrated measurable benefits. A recent implementation study showed that embedding structured pathways in oncology consultations reduced EHR task time by 27% during initial visits and improved clinician perceptions of usability, though less impact was observed during follow-ups (Ebbers et al., \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e). These findings highlight the value of aligning system design with workflow complexity.\\u003c/p\\u003e\\u003cp\\u003ePatient participation represents another underexplored opportunity. Although digital portals provide potential for patient involvement, studies suggest that participation remains limited by digital literacy, time constraints, and technical issues. A qualitative study in the Netherlands found that nurses often relied on verbal discussions with patients before documenting, highlighting gaps in inclusive system design(de Groot et al., \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe use of standardized nursing terminologies has been strongly supported as a means of ensuring consistency and interoperability. A comparative study in the U.S. found that the Omaha System enabled more comprehensive documentation of social and behavioral determinants of health compared with free-text (Monsen et al., 2019). Similarly, oncology nurses in Italy favored ICNP for its flexibility and compatibility with SNOMED-CT, underlining the importance of involving end-users in system development(Togni et al., \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eEmerging evidence suggests that artificial intelligence (AI) can offer meaningful solutions to the challenges of nursing documentation. A recent study evaluated a generative AI\\u0026ndash;based recommendation system designed to support nursing diagnosis and documentation(H. Ju et al., \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e2025b\\u003c/span\\u003e). The system significantly reduced the time required for documentation, while also improving the accuracy and usability of nursing records. These findings indicate that AI tools, when properly integrated into electronic health record systems, can alleviate the administrative burden often reported by nurses and enhance the overall quality of documentation. Importantly, such interventions highlight the potential of combining advanced technologies with standardized nursing terminologies and workflow-centered design, ensuring that digital solutions are not only efficient but also clinically relevant and sustainable in everyday practice.\\u003c/p\\u003e\\u003cp\\u003eThis review highlights the novelty of examining electronic health record (EHR) use in nursing through a socio- technical perspective, emphasizing that system usability, organizational support, and technostress are closely interrelated; that structured care pathways can enhance workflow efficiency; that patient participation remains constrained by design and digital literacy barriers; and that integrating standardized nursing terminologies with artificial intelligence (AI) offers next-generation solutions to improve accuracy and reduce documentation burden. However, several limitations should be acknowledged, including methodological heterogeneity, geographic concentration of studies, reliance on predominantly short-term evidence, and the early stage of AI applications, in addition to potential publication bias. These findings underscore both the potential and complexity of digital nursing documentation while highlighting critical gaps that future research must address. From a practical standpoint, the results emphasize the need for practice-oriented training programs, workflow-aligned system design, and the integration of validated intelligent technologies to reduce administrative burden. Furthermore, strengthening patient\\u003c/p\\u003e\\u003cp\\u003eparticipation through more inclusive digital solutions will ensure that EHRs function not merely as administrative tools but as instruments to enhance care quality, safety, and patient engagement.\\u003c/p\\u003e\"},{\"header\":\"CONCLUSION\",\"content\":\"\\u003cp\\u003eThis systematic review demonstrates that the integration of electronic health records (EHRs) into nursing practice holds substantial potential for improving documentation quality, efficiency, and patient safety. Evidence highlights that successful adoption requires not only robust technical systems but also organizational support, training, and alignment with clinical workflows. While standardized nursing terminologies and structured care pathways contribute to greater consistency and interoperability, challenges such as documentation burden, technostress, and limited patient participation remain significant barriers. Emerging technologies, particularly artificial intelligence, offer promising avenues to alleviate workload and enhance accuracy; however, their application is still at an early stage and requires rigorous validation. Future research should therefore focus on long-term evaluations, inclusive design strategies, and context-specific implementations to ensure that digital nursing documentation evolves as both a clinically effective and user-centered innovation.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eFunding Statement:\\u003c/h2\\u003e\\u003cp\\u003eThis study received no external funding.\\u003c/p\\u003e\\u003cp\\u003eConflict of Interest Statement: The authors declare no conflicts of interest.\\u003c/p\\u003e\\u003cp\\u003eEthics Statement: This study is a systematic review and did not involve human participants; therefore, ethical approval was not required.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eAlkasasbeh, A. M., Jarrah, S. S., Alhusamiah, B. K., \\u0026amp; Tarawneh, F. S. (2025). Factors Influencing the Utilization and Adoption of Electronic Health Records among Nurses in Jordanian Hospitals. \\u003cem\\u003eJordan Journal of Nursing Research\\u003c/em\\u003e, \\u003cem\\u003e4\\u003c/em\\u003e(1), 68\\u0026ndash;80. https://doi.org/10.14525/JJNR.v4i1.08\\u003c/li\\u003e\\n\\u003cli\\u003eAsiri, S. (2024). Factors Influencing Electronic Health Record Workflow Integration Among Nurses in Saudi Arabia:\\u003c/li\\u003e\\n\\u003cli\\u003eCross-Sectional Study. \\u003cem\\u003eSAGE Open Nursing\\u003c/em\\u003e, \\u003cem\\u003e10\\u003c/em\\u003e. https://doi.org/10.1177/23779608241260547\\u003c/li\\u003e\\n\\u003cli\\u003ede Groot, K., Douma, J., Paans, W., \\u0026amp; Franck\\u0026eacute;, A. L. (2022). Patient participation in electronic nursing documentation: An interview study among home-care patients. \\u003cem\\u003eHealth Expectations\\u003c/em\\u003e, \\u003cem\\u003e25\\u003c/em\\u003e(4), 1508\\u0026ndash;1516. https://doi.org/10.1111/hex.13492\\u003c/li\\u003e\\n\\u003cli\\u003eDe Groot, K., Sneep, E. B., Paans, W., \\u0026amp; Francke, A. L. (2021). Patient participation in electronic nursing documentation: an interview study among community nurses. \\u003cem\\u003eBMC Nursing\\u003c/em\\u003e, \\u003cem\\u003e20\\u003c/em\\u003e(1). https://doi.org/10.1186/s12912-021-00590-7\\u003c/li\\u003e\\n\\u003cli\\u003eDouma, M. C., Rejeb, M. Ben, Zardoub, N., Braham, A., Chouchene, H., Bouallegue, O., \\u0026amp; Latiri, H. S. (2024). Impact of Implementing Electronic Nursing Records on Quality and Safety Indicators in Care. \\u003cem\\u003eLibyan Journal of Medicine\\u003c/em\\u003e, \\u003cem\\u003e19\\u003c/em\\u003e(1). https://doi.org/10.1080/19932820.2024.2421625\\u003c/li\\u003e\\n\\u003cli\\u003eDuval Jensen, J., Ledderer, L., \\u0026amp; Beedholm, K. (2023). How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis. \\u003cem\\u003eNursing Inquiry\\u003c/em\\u003e, \\u003cem\\u003e30\\u003c/em\\u003e(1). https://doi.org/10.1111/nin.12499\\u003c/li\\u003e\\n\\u003cli\\u003eEbbers, T., Takes, R. P., Smeele, L. E., Kool, R. B., van den Broek, G. B., \\u0026amp; Dirven, R. (2024). The implementation of a multidisciplinary, electronic health record embedded care pathway to improve structured data recording and decrease electronic health record burden. \\u003cem\\u003eInternational Journal of Medical Informatics\\u003c/em\\u003e, \\u003cem\\u003e184\\u003c/em\\u003e, 105344. https://doi.org/10.1016/j.ijmedinf.2024.105344\\u003c/li\\u003e\\n\\u003cli\\u003eJacques, D., Will, J., Dauterman, D., Zavotsky, K. E., Delmore, B., Doty, G. R., O\\u0026rsquo;Brien, K., \\u0026amp; Groom, L. (2025). Evaluating Nurses\\u0026rsquo; Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis. \\u003cem\\u003eJMIR Nursing\\u003c/em\\u003e, \\u003cem\\u003e8\\u003c/em\\u003e(1). https://doi.org/10.2196/69651\\u003c/li\\u003e\\n\\u003cli\\u003eJu, H., Park, M., Jeong, H., Lee, Y., Kim, H., Seong, M., \\u0026amp; Lee, D. (2025a). Generative AI-Based Nursing Diagnosis and Documentation Recommendation Using Virtual Patient Electronic Nursing Record Data. \\u003cem\\u003eHealthcare Informatics Research\\u003c/em\\u003e, \\u003cem\\u003e31\\u003c/em\\u003e(2), 156\\u0026ndash;165. https://doi.org/10.4258/hir.2025.31.2.156\\u003c/li\\u003e\\n\\u003cli\\u003eJu, H., Park, M., Jeong, H., Lee, Y., Kim, H., Seong, M., \\u0026amp; Lee, D. (2025b). Generative AI-Based Nursing Diagnosis and Documentation Recommendation Using Virtual Patient Electronic Nursing Record Data. \\u003cem\\u003eHealthcare Informatics Research\\u003c/em\\u003e, \\u003cem\\u003e31\\u003c/em\\u003e(2), 156\\u0026ndash;165. https://doi.org/10.4258/hir.2025.31.2.156\\u003c/li\\u003e\\n\\u003cli\\u003eJu, J. K., \\u0026amp; Jeong, H. W. (2025). Effect of a Practice-Oriented Electronic Medical Record Education Program for New Nurses. \\u003cem\\u003eHealthcare (Switzerland)\\u003c/em\\u003e, \\u003cem\\u003e13\\u003c/em\\u003e(4). https://doi.org/10.3390/healthcare13040365\\u003c/li\\u003e\\n\\u003cli\\u003eLaukvik, L. B., Lyngstad, M., Roteg\\u0026aring;rd, A. K., \\u0026amp; Fossum, M. (2024). Utilizing nursing standards in electronic health records: A descriptive qualitative study. \\u003cem\\u003eInternational Journal of Medical Informatics\\u003c/em\\u003e, \\u003cem\\u003e184\\u003c/em\\u003e, 105350. https://doi.org/10.1016/j.ijmedinf.2024.105350\\u003c/li\\u003e\\n\\u003cli\\u003eProvenzano, M., Cillara, N., Curcio, F., Pisu, M. O., Gonz\\u0026aacute;lez, C. I. A., \\u0026amp; Jim\\u0026eacute;nez-Herrera, M. F. (2024). Electronic Health Record Adoption and Its Effects on Healthcare Staff: A Qualitative Study of Well-Being and Workplace Stress. \\u003cem\\u003eInternational Journal of Environmental Research and Public Health\\u003c/em\\u003e, \\u003cem\\u003e21\\u003c/em\\u003e(11). https://doi.org/10.3390/ijerph21111430\\u003c/li\\u003e\\n\\u003cli\\u003eShafiee, M., Shanbehzadeh, M., Nassari, Z., \\u0026amp; Kazemi-Arpanahi, H. (2022). Development and evaluation of an electronic nursing documentation system. \\u003cem\\u003eBMC Nursing\\u003c/em\\u003e, \\u003cem\\u003e21\\u003c/em\\u003e(1). https://doi.org/10.1186/s12912-021-00790-1\\u003c/li\\u003e\\n\\u003cli\\u003eShan, Y., Shang, J., Yan, Y., \\u0026amp; Ye, X. (2023). Workflow interruption and nurses\\u0026rsquo; mental workload in electronic health record tasks: An observational study. \\u003cem\\u003eBMC Nursing\\u003c/em\\u003e, \\u003cem\\u003e22\\u003c/em\\u003e(1). https://doi.org/10.1186/s12912-023-01209-9\\u003c/li\\u003e\\n\\u003cli\\u003eSlawomirski, L., Lindner, L., Bienassis, K. de, Haywood, P., Hashiguchi, T. C. O., Steentjes, M., \\u0026amp; Oderkirk, J. (2023). \\u003cem\\u003eProgress on implementing and using electronic health record systems\\u003c/em\\u003e. https://doi.org/10.1787/4f4ce846-en\\u003c/li\\u003e\\n\\u003cli\\u003eTogni, S., Saracino, L., Cieri, M., Bianco, R., Terzoni, S., Giulia, S. M., Zito, E., Lusignani, M., Silvia, P. M., \\u0026amp; Depalma, L. (2025). Implementing Oncologic Nursing Care Plans in Electronic Health Records With Two Taxonomies: A Pilot Study. \\u003cem\\u003eWestern Journal of Nursing Research\\u003c/em\\u003e, \\u003cem\\u003e47\\u003c/em\\u003e(3), 159\\u0026ndash;168. https://doi.org/10.1177/01939459241310402\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"Airlangga University\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Nursing Documentation Transformation, AI-EHR, Standardized Terminologies \",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7693354/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7693354/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground: \\u003c/strong\\u003eNursing documentation plays a pivotal role in ensuring continuity, quality, and safety of care. The integration of electronic health records (EHRs) has facilitated more accurate and accessible records; however, challenges remain regarding documentation burden, workflow interruptions, and limited patient participation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eObjective: \\u003c/strong\\u003eThis systematic review aimed to identify, evaluate, and synthesize recent evidence on facilitators, barriers, and innovations in electronic nursing documentation, with a particular focus on standardized terminologies and emerging artificial intelligence (AI) applications.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eFollowing PRISMA 2020 guidelines, a comprehensive search of PubMed, Scopus, Web of Science, and CINAHL retrieved 215 records. After duplicate removal and screening, 8 empirical studies published between 2021 and 2025 met the inclusion criteria. Data were extracted and synthesized narratively due to methodological heterogeneity.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eFindings highlight that system usability, organizational support, and adequate training are key enablers of EHR adoption, while infrastructural gaps and technostress pose barriers. Standardized terminologies, including ICNP and the Omaha System, improved documentation consistency and interoperability. Patient participation remained limited, though digital literacy and trust were important factors. Emerging evidence indicates that AI-assisted tools can reduce documentation time, improve accuracy, and alleviate workload.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion: \\u003c/strong\\u003eEHRs hold transformative potential for nursing documentation, yet their success depends on workflow- aligned system design, validated intelligent technologies, and inclusive approaches that enhance both professional practice and patient engagement.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Nursing Documentation Transformation through AI-Enhanced Electronic Health Records and Standardized Terminologies: A Systematic Review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-24 06:24:26\",\"doi\":\"10.21203/rs.3.rs-7693354/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"e7df87f0-a3d4-4107-9245-f9794be0b716\",\"owner\":[],\"postedDate\":\"September 24th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":55186966,\"name\":\"Nursing\"},{\"id\":55186967,\"name\":\"Medical Informatics\"}],\"tags\":[],\"updatedAt\":\"2025-09-24T06:24:26+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-09-24 06:24:26\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7693354\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7693354\",\"identity\":\"rs-7693354\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}