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Related Experiment Videos

Developing a module for nursing documentation integrated in the electronic patient record.

R Hellesø1, C M Ruland

  • 1Institute of Nursing Science, University of Oslo, Norway. ragnhild.helleso@sykepleievit.uio.no

Journal of Clinical Nursing
|February 2, 2002
PubMed
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Five Norwegian hospitals developed a shared framework for nursing documentation within an electronic patient record (EPR) system. This collaboration aims to enhance patient care quality and continuity across the region.

Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Healthcare Management

Background:

  • Regional teaching hospitals in Norway sought to improve patient care quality and continuity.
  • Existing systems lacked integrated nursing documentation within electronic patient records (EPRs).

Purpose of the Study:

  • To develop standardized nursing documentation for an interdisciplinary electronic patient record (EPR).
  • To enhance the quality and continuity of patient care through integrated digital health records.

Main Methods:

  • A collaborative project involving five regional teaching hospitals.
  • Utilized a consensus process to establish common standards for nursing documentation.
  • Focused on defining essential components for EPR implementation.

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Main Results:

  • Agreement reached on a unified framework for nursing documentation across participating hospitals.
  • Key components for implementation in the electronic patient record were identified.
  • Established a foundation for a shared, interdisciplinary EPR system.

Conclusions:

  • A consensus-based framework for nursing documentation is achievable among multiple healthcare institutions.
  • Standardized nursing documentation within an EPR is crucial for improving patient care continuity.
  • The project provides a model for developing integrated electronic patient records in regional healthcare settings.