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Towards a model based electronic nursing record.

Niels Jansen1, Tino Bekkering, Alexander Ruber

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|November 8, 2013
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Summary
This summary is machine-generated.

This study details a nurse-led project defining an electronic nursing record (ENR) using Detail Clinical Models (DCM) in a Dutch hospital. This approach standardizes data for better quality care, independent of specific technology.

Keywords:
DCMclassificationsdetail clinical modelselectronic nursing recordnursing informaticspatient data

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Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Clinical Informatics

Background:

  • The widespread adoption of electronic nursing records (ENR), a component of electronic health records, remains limited in many healthcare settings, including Dutch hospitals.
  • Standardization is crucial for effective data management and exchange in electronic health records.

Purpose of the Study:

  • To describe a nurse-led project for defining and implementing an electronic nursing record system in a Dutch hospital.
  • To highlight the role of Detail Clinical Models (DCM) in standardizing nursing data for improved quality of care.

Main Methods:

  • A requirements analysis was conducted to define the electronic nursing record system.
  • Detail Clinical Models (DCM) were utilized for data standardization, with 28 DCMs incorporated into the ENR specifications.
  • Data elements were mapped to professional terminologies.

Main Results:

  • The project successfully defined an electronic nursing record system tailored to specific needs.
  • The use of DCM facilitated the organization of clinical knowledge and data elements, ensuring semantic interoperability.
  • This approach allows vendors to develop customized solutions for quality care rather than offering fixed products.

Conclusions:

  • Standardization using Detail Clinical Models (DCM) is a viable method for developing effective electronic nursing record systems.
  • This nurse-led, standards-based approach supports the development of technology that prioritizes quality patient care.
  • Implementing standardized electronic nursing records can enhance data management and exchange within healthcare institutions.