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Reinterpreting the Nursing Record for an Electronic Context: Development Principles.

Nicholas R Hardiker¹, Dawn Dowding², Patricia C Dykes^3,4

¹School of Human & Health Sciences, University of Huddersfield, UK.

Studies in Health Technology and Informatics

|July 25, 2024

Summary

This summary is machine-generated.

Electronic health record systems need improvement in nursing documentation. This study explored stakeholder needs to develop better systems supporting nursing practice and data use.

Keywords:

electronic health records nursing nursing records software design user-centred design

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Area of Science:

Health Informatics
Nursing Informatics
Human-Computer Interaction

Background:

Electronic health record (EHR) systems offer potential for care transformation, but their full impact on quality and safety is unrealized.
The nursing component of EHR systems requires reconceptualization regarding structure, content, and utilization to align with clinical practice.
Current EHR documentation methods may not optimally support nursing workflows or facilitate effective data use.

Purpose of the Study:

To explore issues and novel approaches in nursing documentation within EHR systems.
To involve diverse stakeholders, including nurses and EHR developers, in co-designing improved documentation solutions.
To develop principles for a new EHR system specification tailored to nursing practice.

Main Methods:

Conducted three focus groups in the UK and USA.
Utilized a semi-structured interview guide to facilitate discussions.
Employed a common reflexive approach for data analysis.

Main Results:

Findings were synthesized into key themes related to EHR nursing documentation.
Identified specific areas for improvement in EHR structure, content, and data utilization.
Developed a set of development principles to guide future EHR system design for nursing.

Conclusions:

Reconceptualizing EHR nursing documentation is crucial for realizing the full potential of these systems.
Collaborative development involving nurses and developers is essential for creating effective EHR solutions.
The derived principles can inform the design of novel EHR systems that better support nursing practice and data management.