Electronic nursing documentation in a paediatrics hospital: impact on quality of care by using OpenEHR, IHE and HL7

Area of Science:

• Pediatric Nursing
• Respiratory Care
• Health Informatics

Background:

• Increasing acuity of illness in hospitalized children, particularly those with complex conditions and disabilities.
• Respiratory illness is a leading cause of morbidity in young children.
• Nurses are crucial for early identification of respiratory failure through breathing pattern assessment.

Purpose of the Study:

• To review evidence on the impact of electronic health records (EHRs) on nursing care quality.
• To present experiences with electronic nursing documentation for pediatric respiratory assessments.
• To highlight the importance of high-quality record-keeping in patient care.

Main Methods:

• Literature search for evidence on EHRs and nursing care quality.
• Presentation of case experiences with electronic nursing documentation.
• Focus on respiratory assessment in children and young people.

Main Results:

• Good quality record keeping is essential for improving patient care and detecting clinical deterioration.
• Poor documentation standards have contributed to failures in identifying deteriorating patients.
• Electronic nursing documentation in pediatric respiratory care is explored.

Conclusions:

• Electronic health records have the potential to positively impact the quality of nursing care.
• Effective documentation, including electronic methods, is vital for safe and high-quality pediatric respiratory care.
• Further exploration of electronic nursing documentation in this field is warranted.