Reinterpreting the nursing record for an electronic context

Abstract

Background: This article seeks to facilitate the re-imagining of nursing records purposefully within an electronic context. It questions existing approaches to nursing documentation, critically examines existing nursing record systems and identifies new requirements. Methods: A comprehensive literature review was conducted to identify themes, that might meaningfully contribute to a new approach to nursing record systems development, around four key interrelated areas-standards, decision making, abstraction and summarization, and documenting. Studies were analyzed using narrative synthesis to provide a critical analysis of the current 'state of the art', and recommendations for the future. Results: Included studies collectively described aspects of current best practice, both in terms of nursing record systems themselves, and how nurses and other health professionals contribute to and engage with those systems. A number of cross-cutting themes identified more novel approaches taken by nurses to systems development: going back to basics in determining purpose; firming up informatics foundations; nuancing or tailoring to suit different requirements; and engagement, involvement and participation. Conclusion: There is a paucity of research that specifically focuses on the nature of the electronic nursing record and its impact on patient care processes and outcomes. In addition to further research in these areas, there is a need: to reinterpret nurses as knowledge workers rather than as 'data collectors'; to agree on the application in practice of appropriate standards and terminologies; and to work together with system developers to change the ways in which data are captured and care is documented.

Nursing diagnoses focused on universal self‐care requisites

“…This allows the right information on when, where, how and to whom it is needed to be provided 24/7 and improves decision‐making, resulting in significantly better health and financial outcomes (Harrington 2019). EHRs can evolve into clinical decision support systems, giving health professionals information and guidance when a decision needs to be taken (Hardiker et al 2019). An umbrella review conducted to reveal quality criteria, instruments and requisites for nursing documentation concluded that nurse documentation must align with the nursing process and use standard terminologies, user‐friendly formats and systems, to achieve high quality (De Groot et al 2019).…”

“…It contains a set of predefined and agreed‐upon terms structured by nurses (Tastan et al 2014). Deciding upon which standards to use in EHR brings consistency to the process and accuracy, efficiency, reliability and comparability of health information at local, regional, national and international levels (Hardiker et al 2019). To deliver excellent care quality and reduce healthcare costs across health systems in different countries, it is relevant that diverse computer systems share content and its meaning accurately and reliably – semantic interoperability (Gavrilov et al 2019; Harrington 2019).…”

Registros de enfermagem como ferramenta para a gerência do cuidado clínico-hospitalar

“…A baixa qualidade nos registros de enfermagem pode ocasionar problemas graves, que repercutem diretamente na qualidade da assistência e na segurança do paciente, e envolve tanto os profissionais da prática assistencial quanto os gestores, órgãos de classe, pesquisadores e docentes 18 . A adoção de normas e rotinas específicas para as anotações de enfermagem permite padronizar a práticas dos registros, refletindo diretamente na qualidade da assistência, segurança e comunicação 19,20 .…”

The associations of information system’s support and nurses' documentation competence with the detection of documentation-related errors: Results from a nationwide survey

“…33 However, significant shortcomings have been reported in the functions of information systems in terms of how well they support nurses' work and nursing documentation. [34][35][36] Overall, little is known about the role of information system's documentation support and nurses' documentation competence in the detection of documentation-related errors that cause adverse events. However, according to above-mentioned previous research, it can be assumed that if the information system poorly supports nursing documentation, it may also increase the risk of documentation-related errors.…”