Healthcare Informatics Research

Korean Society of Medical Infomatics (대한의료정보학회)
권호 표지

Comparison of Nursing Records of Open Heart Surgery Patients before and after Implementation of Electronic Nursing Record

전자간호기록 도입 전후 개심술 환자의 간호기록 비교 분석

Lee, In-Sil;Park, Hyeoun-Ae
이인실;박현애

  • Published : 20090300
⟨ Previous Next ⟩

Abstract

Objectives: The objective of this study is to compare nursing records before and after the implementation of an electronic nursing records system. Methods: Twenty patients’ paper-based nursing records and 20 patients’ electronic nursing records were analyzed according to the nursing process and compared in terms of quantity and quality. Results: In terms of quantity, the average number of statements documented per patient per day has increased by 2.5 times, from 10.3 to 25.6 statements. The average number of redundancies of a unique statement also has increased by 67%, from 5.0 to 8.8. As for the content of nursing records, paper-based nursing records have more patient problem statements describing signs and symptoms, nursing observations, and patient status. Electronic nursing records have more nursing activity statements. In terms of quality, there were more nursing records following patterns of nursing process in electronic nursing records than paper-based nursing records. The electronic nursing records have a more detailed documentation compared to the paper-based nursing records. Conclusion: After the implementation of electronic nursing record system, quantity of nursing records and the pattern of nursing records following the nursing process have been increased and granularity of nursing records has been improved.

Keywords

References

  1. Jennings BM, Loan LA. Misconceptions among nurses about evidence-based practice. Journal of Nursing Scholarship 2001;33(2):121-127 https://doi.org/10.1111/j.1547-5069.2001.00121.x
  2. Kim HS. Development and application of the computerized nursing process program for orthopedic surgery inpatients. Korean society of nursing science 2005;35(6):979-990
  3. Park HA, Cho IS, Hwang JI, Kwon HG. Nursing Outcome Classification Nursing Classification System Standardization of nursing information. The Journal of Korean Academic Society of Adult Nursing 2000; 12(2):256-266
  4. Voutilainen P, Phil L., Isola A, Muurinen S. Nursing documentation in nursing homes state of the art and implications for quality improvement. Scandinavian Journal of Caring Science 2004;18:72-81 https://doi.org/10.1111/j.1471-6712.2004.00265.x
  5. Larrabee, J.H., Boldreghini, S., Elder-Sorrells,K., Tumer, Z.M., Wender, R.G.,Hart, J.M., Lenzi, P.S. Evaluation of Documentation Before and After Implementation of a Nursing Information System in an Acute Care Hospital. Computers in Nursing 2001; 19(2):56-65
  6. Cho IS & Park HA. Contents Analysis of Paper-based Nursing Documents for Electronic Nursing Record using ICNP. Journal of Korean Society of Medical Informatics 2002;8(3):11-18
  7. HaleCA,ThomasLH,Bond S,ToddC.The nursing record as a research tool to identify nursing interventions. Journal of Clinical Nurse 1997;6:207-214 https://doi.org/10.1111/j.1365-2702.1997.tb00306.x
  8. Gennigberg L. & Ehrenberg A. Accuracy and Quality in the Nursing Documentation of Pressure Ulcers: A comparison of record Content and Patient Examination, JWOCN 2004;31(6):328-335 https://doi.org/10.1097/00152192-200411000-00004
  9. Cho H. The essential function of nursing information system. Korean society of nursing science 1999;20(3): 78-80
  10. Butler M & Bender A. Intensive Care unit Bedside Documentation systems: Realizing cost savings and quality improvements. Computers in Nursing 2004; 17(1):32-38
  11. Zolot JS. Computer-based patient records. American Journal of Nursing 1999;99(12):65-70
  12. Lee JH, Sung YH, Jung YE & Lee JL A study on the effects of EMR on Nursing. Journal of Korean Society of Medical Informatics 2006;(4):87-97
  13. Sung YH, Cho MS & Hong MS. User Satisfaction of Nursing Information System. Journal of Korean Society of Medical Informatics 2006;12(3):227-228
  14. Collection of clinical nursing science papers, Nursing department of Seoul National University Hospital 2005
  15. Kim SK, Kim KN, Kim YK, Seoh SS, et al. The effects of electronic kardex of nursing shift report. Journal of Korean Society ofMedical Informatics 2006;12(2):81-84
  16. Smith DS, Rogers SH & Hood ER. Overtime reduction with the press of a button: An unexpected outcome of computerized documentation, Nursing casemanagement 1998;3(6):266-270
  17. Walker KP & Prophet CM. Nursing Documentation in the Computer-based Patient Record, Nursing Informatics U. IOS press, 1997
  18. Kim YJ. Nursing documentation in nursing notes of cardiac-surgery patients, Journal of Korean Society of Medical Informatics 2005;11(1):45-55
  19. International Classification for Nursing Practice ICNP, Geneva, 1999
  20. Meoung HJ & Park HA. Analysis of nursing notes to develop an ICNP-based electronic nursing record system, 2003
  21. CorneliaM., ElskeA.,AndreasW.,Angelika T., Torsten H., Bettina H. Effects of a Computer-based Nursing Documentation System, Journal of Medical System 2007;31:274-282 https://doi.org/10.1007/s10916-007-9065-0
  22. Lee JH, Kim ES, Lee SW, Kim SA, Min SW, Lim KS. The Effectiveness of Automated Nursing Recording System: Patient Moving Information and Diagnostic Test Information in Emergency Room, Journal of Korean Society of Medical Informatics, 2007;13(2): 123-132
  23. Park SH. Analysis of Direct Nursing Activity and Patient Outcomes Related to Graded Fee of Nursing Management for Inpatient, Korean Academy of Nursing Journal, 2003;33(1):122-129 https://doi.org/10.4040/jkan.2003.33.1.122
  24. Yoo JS. Developing a tool of the neural network modeling for nursing diagnosis, Journal of Korean Society of Medical Informatics,1996;2(2):55-64