Development of an electronic nursing records system based on information models and clinical practice guidelines

The purpose of this study was to test the feasibility of an electronic nursing records system for perinatal care that is based on information models and clinical practice guidelines in perinatal care. We first generated 799 nursing statements describing nursing assessment, diagnoses, interventions, and outcomes using the entities, attributes, and value sets of detailed clinical models for perinatal care that we developed in a previous study. We then extracted 506 detailed recommendations from clinical practice guidelines. Finally, we created sets of nursing statements to be used for nursing documentation by grouping nursing statements based on these detailed recommendations. A prototype electronic nursing records system providing nurses with detailed recommendations for nursing practice and sets of nursing statements based on the detailed recommendations to guide nursing documentation was developed and evaluated.