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Implementation of a next-generation electronic nursing records system based on detailed clinical models and
Yul Ha Min1, Hyeoun-Ae Park2, Eunja Chung3
1College of Nursing, Seoul National University, Seoul, Korea. ; Research Institute of Nursing Science, Seoul National University, Seoul, Korea.
Objectives:
The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system.
Methods:
A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system.
Results:
The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines.
Conclusions:
An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
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