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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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Development and evaluation of an electronic nursing documentation system.

Mohsen Shafiee1, Mostafa Shanbehzadeh2, Zeinab Nassari1

  • 1Department of Nursing, Abadan University of Medical Sciences, Abadan, Iran.

BMC Nursing
|January 11, 2022
PubMed
Summary

This study developed an electronic clinical nursing documentation system (ECNDS) to standardize nursing reports. The system enhances patient care documentation and safety, though further nurse training is recommended.

Keywords:
Electronic health recordElectronic medical recordsHospital information systemNursing processNursing records

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Area of Science:

  • Nursing Informatics
  • Health Information Systems
  • Clinical Documentation

Background:

  • Nursing documentation quality varies, lacking standardization in scientific literature and practice.
  • A unified approach to electronic clinical nursing documentation is needed for consistent reporting.

Purpose of the Study:

  • To design and evaluate the content of an electronic clinical nursing documentation system (ECNDS).
  • To establish a consistent and unified approach to nursing care reporting.

Main Methods:

  • A four-step sequential methodology incorporating a literature review and a two-round Delphi study with expert validation.
  • Development of an ECNDS based on a finalized Minimum Data Set (MDS).
  • End-user evaluation of the developed ECNDS through a survey of 150 registered nurses.

Main Results:

  • A Minimum Data Set (MDS) was established, divided into administrative and clinical sections, including nursing assessment and diagnosis.
  • A modular, layered, web-based ECNDS was developed.
  • The system's impact was evaluated, identifying areas for improvement.

Conclusions:

  • The ECNDS supports legal, ethical, and professional patient care documentation.
  • Further training for nurses on the nursing process and standard reporting templates is essential.
  • The system has the potential to increase patient safety and improve documentation quality.