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Reinterpreting the nursing record for an electronic context.

Nicholas R Hardiker1, Dawn Dowding2, Patricia C Dykes3

  • 1School of Human and Health Sciences, University of Huddersfield, UK.

International Journal of Medical Informatics
|May 27, 2019
PubMed
Summary

This study reimagines electronic nursing records by examining current systems and identifying new requirements. It emphasizes nurses as knowledge workers, advocating for improved documentation and system development for better patient care.

Keywords:
Decision support systemsElectronic health recordNursingQuality indicatorsRequirementsTerminologyUser-computer interface

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Area of Science:

  • Health Informatics
  • Nursing Science

Background:

  • Critically examines current nursing documentation and electronic record systems.
  • Identifies limitations in existing approaches to nursing record-keeping.

Purpose of the Study:

  • To facilitate a re-imagining of electronic nursing records.
  • To identify new requirements for nursing record systems.

Main Methods:

  • Comprehensive literature review on nursing record systems development.
  • Narrative synthesis of studies focusing on standards, decision-making, abstraction, summarization, and documentation.

Main Results:

  • Identified best practices in nursing record systems and user engagement.
  • Highlighted novel approaches including foundational informatics, tailored systems, and participatory development.

Conclusions:

  • Emphasizes the need for more research on electronic nursing records' impact on patient care.
  • Recommends reinterpreting nurses as knowledge workers and collaborative system development.