Evaluation of electronic documentation of the nursing process based on the classification of nursing diagnoses and the ICNP dictionary

Abstract

Introduction: In teaching nursing, new technologies are used as tools to support patient care and for the standardization of the nursing language, and as part of distance learning. At the Faculty of Health Sciences of the Jagiellonian University Medical College in Cracow, an attempt was made to implement electronic nursing medical documentation, based on the International Classification for Nursing Practice (ICNP ® ) dictionary, for teaching as part of the Fundamentals of Nursing subject, implemented during the first year of studies in the field of Nursing. Aim of the study: To evaluate the electronic documentation of the nursing process using the ICNP ® dictionary, and to show the importance of the electronic patient record in documenting nursing practice and teaching. Material and methods: 158 students of the first year of undergraduate studies in Nursing took part in the study. The study used an original questionnaire. Results:The study proved that the technology used supports students in collecting data about patients, and to a lesser extent it facilitates the diagnosis of nurses and the development of care plans, as well as documenting their implementation, and ongoing and final evaluation. The difficulties can be explained by the lack of experience in patient care and only basic knowledge acquired during the first year of studies. Conclusions: Students noticed the advantages and validity of keeping electronic documentation of the nursing process based on ICNP®, but its performance should be improved. Moreover, the students also pointed out some shortcomings of electronic patient records.