Narrative notes in a nursing information system (NIS)

Today s rapidly changing health care environment creates pressure for the computerization of the patient record. Two requirements for inclusion of nursing activities into the computerized patient record (CPR) are a standardized nursing language of sufficient granularity and a database that allows for one time collection of data for multiple uses. Documentation systems raise issues of data completeness. Using a descriptive methodology, nursing documentation in one CPR was examined for prevalence and content of free text documentation in an otherwise structured nursing information system (NIS). Results demonstrate house wide use of free text (narrative note) fields. Variability in use unrelated to patient acuity suggests idiosyncratic individual or unit documentation practices. Findings support the use of quality management activities to improve documentation practices and point to areas of database enhancement and information system development.