Impacts of structuring nursing records: a systematic review

Area of Science:

• Nursing Informatics
• Health Information Management
• Clinical Documentation

Background:

• Nursing records and care plans utilize various data structuring methods.
• Evaluating the impact of these structures on healthcare input, processes, and outcomes is crucial.
• Standardized Nursing Language (SNL) is one such structuring method with potential benefits.

Purpose of the Study:

• To systematically review and describe the impacts of different data structuring methods in nursing records and care plans.
• To identify evaluated structuring methods and their effects on healthcare.
• To analyze the influence of data structures on healthcare input, processes, and outcomes.

Main Methods:

• A systematic literature search was conducted across 15 databases.
• Studies were selected based on Population, Intervention, Comparators, and Outcomes (PICO) criteria.
• Thirty-eight empirical studies were included in the final analysis after data extraction and classification.

Main Results:

• The most common study design was single measurement without control, often in secondary or tertiary care settings.
• Nursing process models and nursing classifications were frequently used documentation standards.
• Standardized Nursing Language (SNL) use enhanced descriptions of nursing interventions and outcomes, improving patient safety and data reuse.

Conclusions:

• Nursing process models and classifications are internationally adopted data structures for nursing records.
• SNL demonstrates positive impacts on daily workflow, nursing care delivery, and data reuse, enhancing continuity of care and patient safety.
• Inconsistent SNL study indexing, varied study designs, and lack of resources can impede benefits; further education and managerial support are needed for nurses.