Development and evaluation of a terminology-based electronic nursing record system

Area of Science:

• Nursing Informatics
• Health Information Systems

Background:

• Electronic nursing records are crucial for patient care.
• Standardized terminology enhances data consistency and analysis.
• Existing systems may not fully capture nursing practice nuances.

Purpose of the Study:

• To develop and evaluate a terminology-based electronic nursing record system.
• To assess the system's usability and impact on nursing documentation.
• To identify gaps between nursing documentation and existing terminologies like ICNP.

Main Methods:

• Decomposition and cross-mapping of 395 hospital days of nursing notes from 63 obstetric patients with the Korean ICNP beta version.
• Development of a terminology server for managing nursing concepts and phrases, and a user application system.
• Evaluation of the system by 20 nurses in two Korean hospitals documenting notes for 57 patients.

Main Results:

• Identified patterns in nursing notes reflecting the nursing process.
• Extracted 259 unique nursing concepts from 14,727 phrases, with 39.8% not mapping to ICNP.
• Achieved an 89.4% success rate in finding nursing phrases.
• Reduced mean documentation time from 276 to 158 seconds with user experience.

Conclusions:

• The developed system effectively manages nursing terminology and supports documentation.
• Significant gaps exist between current nursing documentation and the ICNP terminology.
• The system demonstrates potential for improving nursing informatics and standardizing nursing language.