Reviewing the evidence on nursing record systems

Abstract

The aim of this article is to examine the relationship between nursing practice and the recording of practice. We outline the main findings of a Cochrane systematic review on nursing records, discussing the indications from the included studies that compared computerized nursing care planning with paper-based systems. Qualitative research on nursing records systems, and other survey evidence, is collated to answer questions on the format of the record (structured versus free text, for what type of practice), occasions when information exchange about nursing care may not and should not be recorded formally, and the effective organization of the nursing record. We conclude that more research is required to answer these questions, as it seems that computerization does not always bring the expected benefits, and outcomes for patient care are not clear. IntroductionA systematic review [1] of the effect of nursing record systems on nursing practice found no evidence of effects on practice attributable to changes in record systems. Although there was a paucity of studies of sufficient methodological rigour for a Cochrane review to yield reliable results in this area, it is clear from the literature that it is possible to set up randomized trials or other quasi-experimental designs needed to produce evidence for practice. The review identified a need for research into the relationship between clinical practice and its understanding and written expression by nurses.

Review: evaluating information systems in nursing

“…It is widely recognized that structured data entry and the use of formalized nursing language in a Nursing Information System (NIS) can contribute to a better data capture by nurses (Nahm & Poston 2000, Daly et al. 2002, Urquhart & Currell 2005). In addition, structured formats and predefined care plans make planning activities easier and more effective and records are more complete (Ammenwerth 2001a).…”

A quantitative analysis of the impact of a computerised information system on nurses’ clinical practice using a realistic evaluation framework

“…One of the main problems identified in the literature in relation to the utility of IT systems is the lack of adaptation to workflow and, therefore, IT systems not being clinically relevant, but being designed for legal or management purposes [2]. Patient care should be the main aim of an IT system, it has to be clinically relevant and adapted to workflow.…”

Social science and linguistic text analysis of nurses’ records: a systematic review and critique

“…Urquhart and Currell () followed up on their Cochrane review by synthesising it with a selection of qualitative studies on recording systems in nursing. Their aim was to discuss the relationship between nursing practice and nurses’ recording practices, and the conclusion was that more research was needed to address this complex issue.…”