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Effects of terminology based documentation on nursing
Ulla-Mari Kinnunen1, Kaija Saranto, Merja Miettinen
1Kuopio University Hospital, Kuopio, Finland. ulla-mari.kinnunen@kuh.fi
Studies in Health Technology and Informatics
|July 14, 2009
Summary
Standardized nursing documentation, utilizing nursing terminologies, shows predominantly positive effects on patient care documentation. This literature review synthesized 19 studies from 2007-2008.
Area of Science:
- Nursing
- Health Informatics
Background:
- Standardized nursing documentation is crucial for consistent patient care.
- The impact of specific documentation methods requires investigation.
Purpose of the Study:
- To review the effects of standardized nursing documentation.
- To identify the outcomes of using nursing terminologies in patient records.
Main Methods:
- Literature review synthesizing studies from CINAHL, PubMed, and Cochrane databases.
- Included electronically retrievable, full-text English articles published between 2007-2008.
- Analysis of 19 selected studies.
Main Results:
- The use of standardized nursing terminologies in documentation yields primarily positive effects.
- Consistent terminology enhances the clarity and quality of patient care records.
Conclusions:
- Implementing standardized nursing terminologies is beneficial for patient care documentation.
- Further research may explore specific terminology impacts across different healthcare settings.
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