Workflow interruption and nurses' mental workload in electronic health record tasks: An observational study.

BACKGROUND: Workflow interruptions are common in modern work systems. Electronic health record (EHR) tasks are typical tasks involving human-machine interactions in nursing care, but few studies have examined interruptions and nurses' mental workload in the tasks. Therefore, this study aims to investigate how frequent interruptions and multilevel factors affect nurses' mental workload and performance in EHR tasks. METHODS: A prospective observational study was conducted in a tertiary hospital providing specialist and sub-specialist care from June 1st to October 31st, 2021. An observer documented nurses' EHR task interruptions, reactions and performance (errors and near errors) during one-shift observation sessions. Questionnaires were administered at the end of the electronic health record task observation to measure nurses' mental workload for the electronic health record tasks, task difficulty, system usability, professional experience, professional competency, and self-efficacy. Path analysis was used to test a hypothetical model. RESULTS: In 145 shift observations, 2871 interruptions occurred, and the mean task duration was 84.69 (SD 56.68) minutes per shift. The incidence of error or near error was 158, while 68.35% of errors were self-corrected. The total mean mental workload level was 44.57 (SD 14.08). A path analysis model with adequate fit indices is presented. There was a relationship among concurrent multitasking, task switching and task time. Task time, task difficulty and system usability had direct effects on mental workload. Task performance was influenced by mental workload and professional title. Negative affect mediated the path from task performance to mental workload. CONCLUSIONS: Nursing interruptions occur frequently in EHR tasks, come from different sources and may lead to elevated mental workload and negative outcomes. By exploring the variables related to mental workload and performance, we offer a new perspective on quality improvement strategies. Reducing harmful interruptions to decrease task time can avoid negative outcomes. Training nurses to cope with interruptions and improve competency in EHR implementation and task operation has the potential to decrease nurses' mental workload and improve task performance. Moreover, improving system usability is beneficial to nurses to mitigate mental workload.

Effekte von Guided Clinical Reasoning auf die Qualität des Advanced Nursing Process.

Effects of Guided Clinical Reasoning on the Advanced Nursing Process quality - An experimental intervention study Abstract. Background: The correctly applied Advanced Nursing Process leads demonstrably to more accurate nursing diagnoses and better nursing outcomes. It requires nurses' knowledge, clinical decision-making competency, and a positive attitude. Former Guided Clinical Reasoning (GCR) trainings significantly enhanced the Advanced Nursing Process quality. However, the congruence between nursing records, care situations, and patient interviews was not yet investigated. Research question: Which effects has GCR on nurses' knowledge, attitude, clinical performance, and on the quality of the Advanced Nursing Process? Methods: An experimental intervention study was carried out from 2016 until 2018 in a Swiss hospital. The 5-month intervention contained four seminar days and GCR-case meetings and was investigated by an evaluation model (n = 95 nurses, n = 24 patients, n = 225 nursing records). Results: After GCR training, nurses showed greater knowledge (p < 0,0001) and a more positive attitude (p = 0,004) on the Advanced Nursing Process than the control group. The congruence of nursing diagnoses, interventions, and outcomes between observations, interviews, and nursing records was higher in the intervention group. At the last measurement point, nursing diagnoses were stated significantly more accurate, interventions were more effective, and better patient outcomes were achieved (all p < 0,0005). Conclusions: GCR trainings should be used to enhance the Advanced Nursing Process quality, so that based on more accurate nursing diagnoses better patient outcomes are achieved.

The consistency between planned and actually given nursing care in long-terminstitutional care.

Continuous information exchange between healthcare professionals is facilitated by individualized care plans. Compliance with the planned care as documented in care plans is important to provide person-centered care which contributes to the continuity of care and quality of care outcomes. Using the Nursing Interventions Classification, this study examined the consistency between documented and actually provided interventions by type of nursing staff with 150 residents in long-term institutional care. The consistency was especially high for basic (93%) and complex (79%) physiological care. To a lesser extent for interventions in the behavioral domain (66%). Except for the safety domain, the probability that documented interventions were provided was high for all domains (≥ 91%, p > 0.05). NAs generally provided the interventions as documented. Findings suggest that HCAs worked beyond there scope of practice. The results may have implications for the deployment of nursing staff and are of importance to managers.

Developing a prenatal nursing care International Classification for Nursing Practice catalogue.

AIM: This study aimed to develop a prenatal nursing care catalogue of International Classification for Nursing Practice. BACKGROUND: As a programme of the International Council of Nurses, International Classification for Nursing Practice aims to support standardized electronic nursing documentation and facilitate collection of comparable nursing data across settings. This initiative enables the study of relationships among nursing diagnoses, nursing interventions and nursing outcomes for best practice, healthcare management decisions, and policy development. The catalogues are usually focused on target populations. Pregnant women are the nursing population addressed in this project. METHODS: According to the guidelines for catalogue development, three research steps have been adopted: (a) identifying relevant nursing diagnoses, interventions and outcomes; (b) developing a conceptual framework for the catalogue; (c) expert's validation. RESULTS: This project established a prenatal nursing care catalogue with 228 terms in total, including 69 nursing diagnosis, 92 nursing interventions and 67 nursing outcomes, among them, 57 nursing terms were newly developed. All terms in the catalogue were organized by a framework with two main categories, i.e. Expected Changes of Pregnancy and Pregnancy at Risk. Each category had four domains, representing the physical, psychological, behavioral and environmental perspectives of nursing practice. IMPLICATIONS FOR NURSING PRACTICE: This catalogue can ease the documentation workload among prenatal care nurses, and facilitate storage and retrieval of standardized data for many purposes, such as quality improvement, administration decision-support and researches. The documentations of prenatal care provided data that can be more fluently communicated, compared and evaluated across various healthcare providers and clinic settings.

Analysis of complications of prone position in acute respiratory distress syndrome: quality standard, incidence and related factors. / Análisis de las complicaciones del decúbito prono en el síndrome de distrés respiratorio agudo: estándar de calidad, incidencia y factores relacionados.

INTRODUCTION: The monitoring system based on standards of quality allows clinicians to evaluate and improve the patient's care. According to the quality indicators recommended by Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias, and due to the importance of prone position (PP) as a treatment in patients with acute respiratory distress syndrome, it is fundamental to keep accurate record of serious adverse events occurring during the prone position procedure and its posterior analysis. OBJECTIVES: To establish fulfilment of the Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias standards of quality according to the register of serious complications. To identify the incidence of serious complications registered as well as to identify possible factors related to these complications. METHOD: Retrospective, cross-sectionsl descriptive study, polyvalent ICU (16 beds). Study population Patients with acute respiratory distress syndrome treated with PP (January 2012-December 2013). Study variables PP recording, accidental extubation, removal of catheters, decubitus ulcers (DU), ETT obstruction, urgency of the procedure, hours in PP, nutritional intake, type of feeding tube, food regurgitation/retention and use of prokinetics/muscle relaxant. RESULTS: The study sample comprised 38 cases, with an adequate record of complications in 92.1% of the cases. DU were the only serious complication recorded, with a 25.7% incidence. Possible factors related to DU: more hours in PP in patients developing DU (p= .067). Less incidence of DU in well-nourished patients (p= .577). 82.9% of patients were not appropriately nourished. CONCLUSIONS: The percentage of records duly completed is very high. The presence of DU (grade 1-2 mostly) is to be noted. There is no stastistical significance, although a trend is obversed, between DU and hours in PP.

[The regulation of nursing record-keeping]. / La réglementation des écrits professionnels.

Record-keeping guarantees a permanent trace of a patient's treatment and the legal protection of the nurse. Legislation provides a regulatory framework. It is also a matter of professionalisation and improvement of practices.

[Professional practice and nursing records]. / Pratique professionnelle et dossier de soins.

Nursing record-keeping has evolved over the ages and has several functions. It is an act which provides proof of the professional's responsibility. These records reinforce notably the competencies of the caregivers and the collaboration of the patient.

Development of a Nursing Diagnosis/Record Generative AI System Based on Virtual Patient Data.

This study investigates how to reduce nurses' repetitive electronic nursing record tasks. We applied generative AI by learning nursing record data practiced with virtual patient data. We aim to evaluate generative AI's usefulness, usability, and availability when applied to nursing record creation tasks. The nursing record data collected through the electronic nursing record system for nursing students without privacy issues is in the form of NANDA, FocusDAR, SOAPIE, and narrative records. We trained 50,000 nursing record data and upgraded the performance through generative AI and fine-tuning. A separate API was used to connect with the practice electronic nursing record system, and 40 experienced nurses from a university hospital conducted tests. The electronic nursing record, through generative AI, is expected to contribute to easing the workload of nurses.

The quality of nursing documentation and standardized nursing diagnoses in the children's hospital electronic nursing records.

AIM: The aim of the paper is to compare the quality of nursing documentation in the Children's Hospital before and after the NANDA-I nursing diagnoses training. METHODS: Research employed the interventional study design, and pre-post study design. Before and after the NANDA-I nursing diagnoses training, 50 nursing records were analyzed in the interventional pre-post study, using D-Catch instrument. RESULTS: The most often documented problem-centered nursing diagnosis before training was anxiety and after the training, hyperthermia. The most common risk diagnoses before and after the training was risk of infection. Before the training, one health promotion diagnosis was determined in the nursing records, and after the training the number increased to four. The highest value was given to readability of the nursing documentation both before and after the training. The lowest score before the training was given to the quality determiners of the accurate nursing diagnoses and after the training given to the determiners of the results' quantity. The sum score of documenting the nursing interventions was the most inconsistent before the training and after the training. The most consistent was the readability of the nursing records before and after the training. Statistically significant differences in the improvement of quality were revealed in all areas except for the readability of the nursing documentation and the quantity of nursing assessment. CONCLUSIONS: The results of the study revealed that following the training, the quality of nursing documentation improved, the wording of the nursing diagnoses improved, and the number of accurate nursing diagnoses had increased. IMPLICATIONS FOR NURSING PRACTICE: Results of the research provide an overview of the importance of the training in improving the quality of nursing documentation and aid the educators in planning the trainings, focusing more on the challenges in the documentation.

Impact of an Electronic Medical Record-Connected Questionnaire on Efficient Nursing Documentation: Usability and Efficacy Study.

BACKGROUND: Documentation tasks comprise a large percentage of nurses' workloads. Nursing records were partially based on a report from the patient. However, it is not a verbatim transcription of the patient's complaints but a type of medical record. Therefore, to reduce the time spent on nursing documentation, it is necessary to assist in the appropriate conversion or citation of patient reports to professional records. However, few studies have been conducted on systems for capturing patient reports in electronic medical records. In addition, there have been no reports on whether such a system reduces the time spent on nursing documentation. OBJECTIVE: This study aims to develop a patient self-reporting system that appropriately converts data to nursing records and evaluate its effect on reducing the documenting burden for nurses. METHODS: An electronic medical record-connected questionnaire and a preadmission nursing questionnaire were administered. The questionnaire responses entered by the patients were quoted in the patient profile for inpatient assessment in the nursing system. To clarify its efficacy, this study examined whether the use of the electronic questionnaire system saved the nurses' time entering the patient profile admitted between August and December 2022. It also surveyed the usability of the electronic questionnaire between April and December 2022. RESULTS: A total of 3111 (78%) patients reported that they answered the electronic medical questionnaire by themselves. Of them, 2715 (88%) felt it was easy to use and 2604 (85%) were willing to use it again. The electronic questionnaire was used in 1326 of 2425 admission cases (use group). The input time for the patient profile was significantly shorter in the use group than in the no-use group (P<.001). Stratified analyses showed that in the internal medicine wards and in patients with dependent activities of daily living, nurses took 13%-18% (1.3 to 2 minutes) less time to enter patient profiles within the use group (both P<.001), even though there was no difference in the amount of information. By contrast, in the surgical wards and in the patients with independent activities of daily living, there was no difference in the time to entry (P=.50 and P=.20, respectively), but there was a greater amount of information in the use group. CONCLUSIONS: The study developed and implemented a system in which self-reported patient data were captured in the hospital information network and quoted in the nursing system. This system contributes to improving the efficiency of nurses' task recordings.

Evaluation of a Web Application for Nursing Records of Multiple Trauma Patients in an Emergency Department.

Introduction: Multiple traumatic injuries cause death among traumatized patients. Nurses at the emergency department (ED) must assess, provide nursing care, and record their interventions. Recording all patient information and nursing care procedures, however, is more challenging due to time constraints in emergency care. Methods: The aim of this study was to evaluate the use of a web application for nursing records of multiple trauma patients in an ED and the user's satisfaction. A web application developed based on the guidelines of Advanced Trauma Life Support was implemented in a resuscitation room of a university hospital in Khon Kaen, Thailand, from January to March 2022. The quality of nursing records through the web application for 40 trauma patients was evaluated. Thirty-seven nurses were surveyed for their satisfaction. The data were analyzed using descriptive statistics. Results: Overall, the comprehensive nursing process record through web application had 80.3% completeness. Some items were not recorded or partially recorded, including vital sign monitoring and patients' vital signs and symptoms summary records before discharge. Nurses expressed their satisfaction with the web application at a high level, with an average score of 3.99 (standard deviation [SD]: 0.68). They were most satisfied with the components of the nursing process for multiple trauma patients (mean: 4.14 and SD: 0.71). Conclusions: The use of a web application ensures the completeness of nursing records. Nurses are satisfied with implementing the web application in their clinic. A study of its effectiveness in reducing documentation time and improving patient outcomes is needed in the future.

Integrating a spoken dialogue system, nursing records, and activity data collection based on smartphones.

BACKGROUND AND OBJECTIVE: This study describes the integration of a spoken dialogue system and nursing records on an Android smartphone application intending to help nurses reduce documentation time and improve the overall experience of a healthcare setting. The application also incorporates with collecting personal sensor data and activity labels for activity recognition. METHODS: We developed a joint model based on a bidirectional long-short term memory and conditional random fields (Bi-LSTM-CRF) to identify user intention and extract record details from user utterances. Then, we transformed unstructured data into record inputs on the smartphone application. RESULTS: The joint model achieved the highest F1-score at 96.79%. Moreover, we conducted an experiment to demonstrate the proposed model's capability and feasibility in recording in realistic settings. Our preliminary evaluation results indicate that when using the dialogue-based, we could increase the percentage of documentation speed to 58.13% compared to the traditional keyboard-based. CONCLUSIONS: Based on our findings, we highlight critical and promising future research directions regarding the design of the efficient spoken dialogue system and nursing records.

Nursing diagnosis identification by nurses in burn wards: A descriptive cross-sectional study.

Aim: To identify and document patients' care needs, it is vital to provide quality care services. This study was aimed to describe care needs derived from records of patients with burn and to evaluate whether nurses employed the North American Nursing Diagnosis Association classification to formulate patients' care needs. Design: A descriptive cross-sectional study. Methods: In this study using the convenient sampling method, 430 nursing records reviewed in the burn wards. Data were collected using Gordon's checklist. The validity of the checklist assessed by content validity and the reliability of them calculated with inter-rater and internal consistency. Data analysed by SPSSv.24. Results: The mean number of diagnoses per record was 1.94. The most frequent diagnosis was in the domain of Safety/Protection and the top two prevalent nursing diagnoses in Sina hospital were a risk for infection and risk for falls. From all of the detected diagnostic, about 83% were determinedly not related to one of 247 labels of the North American Nursing Diagnosis Association. Given that nurses provide nursing care as requested by physicians and patient care needs are not assessed and recorded by them, it can be concluded that there was no nursing thinking behind their nursing care.

Automatic Labeled Dialogue Generation for Nursing Record Systems.

The integration of digital voice assistants in nursing residences is becoming increasingly important to facilitate nursing productivity with documentation. A key idea behind this system is training natural language understanding (NLU) modules that enable the machine to classify the purpose of the user utterance (intent) and extract pieces of valuable information present in the utterance (entity). One of the main obstacles when creating robust NLU is the lack of sufficient labeled data, which generally relies on human labeling. This process is cost-intensive and time-consuming, particularly in the high-level nursing care domain, which requires abstract knowledge. In this paper, we propose an automatic dialogue labeling framework of NLU tasks, specifically for nursing record systems. First, we apply data augmentation techniques to create a collection of variant sample utterances. The individual evaluation result strongly shows a stratification rate, with regard to both fluency and accuracy in utterances. We also investigate the possibility of applying deep generative models for our augmented dataset. The preliminary character-based model based on long short-term memory (LSTM) obtains an accuracy of 90% and generates various reasonable texts with BLEU scores of 0.76. Secondly, we introduce an idea for intent and entity labeling by using feature embeddings and semantic similarity-based clustering. We also empirically evaluate different embedding methods for learning good representations that are most suitable to use with our data and clustering tasks. Experimental results show that fastText embeddings produce strong performances both for intent labeling and on entity labeling, which achieves an accuracy level of 0.79 and 0.78 f1-scores and 0.67 and 0.61 silhouette scores, respectively.

Predicting Inpatient Falls Using Natural Language Processing of Nursing Records Obtained From Japanese Electronic Medical Records: Case-Control Study.

BACKGROUND: Falls in hospitals are the most common risk factor that affects the safety of inpatients and can result in severe harm. Therefore, preventing falls is one of the most important areas of risk management for health care organizations. However, existing methods for predicting falls are laborious and costly. OBJECTIVE: The objective of this study is to verify whether hospital inpatient falls can be predicted through the analysis of a single input-unstructured nursing records obtained from Japanese electronic medical records (EMRs)-using a natural language processing (NLP) algorithm and machine learning. METHODS: The nursing records of 335 fallers and 408 nonfallers for a 12-month period were extracted from the EMRs of an acute care hospital and randomly divided into a learning data set and test data set. The former data set was subjected to NLP and machine learning to extract morphemes that contributed to separating fallers from nonfallers to construct a model for predicting falls. Then, the latter data set was used to determine the predictive value of the model using receiver operating characteristic (ROC) analysis. RESULTS: The prediction of falls using the test data set showed high accuracy, with an area under the ROC curve, sensitivity, specificity, and odds ratio of mean 0.834 (SD 0.005), mean 0.769 (SD 0.013), mean 0.785 (SD 0.020), and mean 12.27 (SD 1.11) for five independent experiments, respectively. The morphemes incorporated into the final model included many words closely related to known risk factors for falls, such as the use of psychotropic drugs, state of consciousness, and mobility, thereby demonstrating that an NLP algorithm combined with machine learning can effectively extract risk factors for falls from nursing records. CONCLUSIONS: We successfully established that falls among hospital inpatients can be predicted by analyzing nursing records using an NLP algorithm and machine learning. Therefore, it may be possible to develop a fall risk monitoring system that analyzes nursing records daily and alerts health care professionals when the fall risk of an inpatient is increased.

Designing and implementing an electronic nursing record to support compassionate and person-centred nursing practice in an acute hospital using practice development processes.

BACKGROUND: The complexity of nursing practice can pose challenges to the development of an e-record that meets all the requirements and standards whilst capturing the essence of the relationship between the nurse and his/her patients. AIMS: 1. Describe the process of designing the content of an electronic nursing record (e-record) specific to nursing in an Irish/UK context, using Practice Development (PD) methodology.2. To share the learning of involving the end-user in the development of a person-centred e-nursing record. METHODS: Evidence-based PD methodologies, principles and evaluation tools were employed to involve end users in the development of a person-centred and evidence-based e-record. RESULTS: The results are limited to evaluation of the design process and reported using the SQUIRE guidelines for reporting quality improvement. Investing in time to involve end users in the design and implementation phase resulted in satisfaction and adoption of the e-record by nurses. CONCLUSIONS: For nurses to be satisfied with the content and process flow of an e-nursing record it needs to include the relational and non-clinical aspect of nursing practice in addition to the clinical pre-set content. Involving the end user in a meaningful way supports a positive outcome.

Criteria-Based Evaluation of Human-Computer Interfaces Used for Entering Narrative Nursing Notes in Six Electronic Medical Record Systems.

This study investigated the human-computer interfaces used for entering narrative nursing notes in the electronic medical record systems at six Korean hospitals. Using a criteria-based evaluation tool consisting of 17 elements revealed scores of 3.5-6.5. This implies that many criteria were not fulfilled and that considerable improvement is needed.

Implementation of transoperative and immediate postoperative nursing diagnoses in the computerized management system / Implementación de diagnósticos de enfermería intraoperatorios y postoperatorios inmediatos en el sistema de gestión informatizado / Implementação dos diagnósticos de enfermagem do transoperatório e pós-operatório imediato no sistema de gestão informatizado

ABSTRACT Objective: To implement, on health management software, electronic records of the perioperative nursing process and the stages of transoperative and immediate postoperative nursing diagnoses, based on the NANDA International taxonomy. Method: Experience report conducted from the completion of the Plan-Do-Study-Act cycle, which allows improvement planning with a clearer purpose, directing each stage. This study was carried out in a hospital complex in southern Brazil, using the software Tasy/Philips Healthcare. Results: For the inclusion of nursing diagnoses, three cycles were completed, predictions of expected results were established, and tasks were assigned, defining "who, what, when, and where". The structured model covered seven possibilities of aspects, 92 symptoms and signs to be evaluated, and 15 nursing diagnoses to be used in the transoperative and immediate postoperative periods. Conclusion: The study allowed implementing electronic records of the perioperative nursing process on health management software, including transoperative and immediate postoperative nursing diagnoses, as well as nursing care.

RESUMEN Objetivo: Implementar, en un software de manejo de la salud, registros electrónicos del proceso de enfermería perioperatorio y la etapa de diagnósticos de enfermería transoperatorios y postoperatorios inmediatos, con base en la taxonomía NANDA internacional. Método: Informe de experiencia realizado a partir de la consecución del ciclo Plan-Do-Study-Act), que permite planificar la mejora con un propósito más claro, dirigiendo cada etapa. Este estudio fue realizado en un complejo hospitalario en el sur de Brasil, utilizando el Software Tasy/Philips Healthcare. Resultados: Para la inclusión de diagnósticos de enfermería, se concluíran tres ciclos, se estableceran predicciones de los resultados esperados, y se asignaron tareas, definiendo "quién, qué, cuándo y dónde". El modelo estructurado contempló siete posibles aspectos, 92 signos y síntomas para ser evaluados y 15 diagnósticos de enfermería para ser utilizados en el transperatorio y postoperatorio inmediato. Conclusión: El estudio permitió implementar, en un software de manejo de la salud, registros electrónicos del proceso de enfermería perioperatorio, que comprende diagnósticos de enfermería transoperatoria y postoperatoria inmediata, además de los cuidados de enfermería.

RESUMO Objetivo: Implementar, em um software de gestão em saúde, os registros eletrônicos do processo de enfermagem perioperatório e a etapa de diagnósticos de enfermagem transoperatório e pós-operatório imediato, fundamentados na taxonomia NANDA International. Método: Relato de experiência conduzido a partir da realização do ciclo PDSA (Plan-Do-Study-Act), o qual permite o planejamento de melhoria com um propósito mais claro, direcionando cada etapa. Este estudo foi realizado em um complexo hospitalar da região sul do Brasil, utilizando o software Tasy/Philips Healthcare. Resultados: Para a inclusão dos diagnósticos de enfermagem, rodaram-se três ciclos, estabeleceram-se previsões de resultados esperados, e as tarefas foram atribuídas, definindo "quem, o quê, quando e onde". O modelo estruturado contemplou sete possibilidades de aspectos, 92 sinais e sintomas a serem avaliados e 15 diagnósticos de enfermagem para serem utilizados no transoperatório e pós-operatório imediato. Conclusão: O estudo possibilitou implementar, em um software de gestão em saúde, os registros eletrônicos do processo de enfermagem perioperatório, compreendendo diagnósticos de enfermagem do transoperatório e pós-operatório imediato, além de cuidados de enfermagem.

Development of Observation Support System Using Integrated Nursing Practice Data.

The purpose of this study was to develop a prototype nursing observation support system using integrated nursing practice data with nursing records, prescription data, and nurse call logs. These data show that the present observation system has improved. The system has the potential to provide improved observations of chest symptoms and pain management.

Effects of a sexual health care nursing record on the attitudes and practice of oncology nurses.

BACKGROUND: A nursing record focused on sexual health care for patients with cancer could encourage oncology nurses to provide sexual health care for oncology patients in a simple and effective manner. However, existing electronic information systems focus on professional use and not sexual health care, which could lead to inefficiencies in clinical practice. OBJECTIVE: To examine the effects of a sexual health care nursing record on the attitudes and practice of oncology nurses. METHODS: Twenty-four full-time registered nurses caring for oncology patients were randomly assigned to the intervention and control groups in Korea. The researchers developed a sexual health care record and applied it to the intervention group for one month. Data were analyzed by Mann-Whitney U test and chi-square test. Content analysis was used to analyze interviews. RESULTS: Oncology nurses using the sexual health care record had significantly higher levels of sexual health care practice at 4 weeks post-intervention as compared to those who provided usual care to patients with cancer. CONCLUSION: A sexual health care record may have the potential to facilitate oncology nurses' practice of sexual health care. This study highlighted the importance of using SHC records with oncology patients to improve nursing practice related to sexuality issues. A nursing record focused on SHC for patients with cancer could make it easier and more effective for oncology nurses to provide such care to their patients.