Evaluation of the completeness of the nursing process for patients having gastrectomy using electronic nursing records.

The purpose of this study was to evaluate recording completeness of the nursing process. We compared nursing statements documented at the time when the Electronic Nursing Record (ENR) system, based on the ICNP, was implemented in 2004 with those documented in 2007. The ENRs for 35 gastrectomy patients in each year were selected for evaluation. The selected data were 11,822 nursing statements in 2004 and 27,870 in 2007. The results indicated a significant increase in the completeness of the nursing process in 2007. In addition, the number of nursing diagnosis increased by 5.1 times. The most contributing factor for this increase is assumed to be nurse education.

Comparison of direct and indirect nursing-care times between physician order entry system and electronic medical records.

This study compared the amount of time spent by nursing personnel on direct and indirect nursing care between a physician order entry (POE) system and an electronic medical record (EMR) system. Nursing-care time was measured by direct observation or a self-reporting method, both using a stopwatch. Nursing activities were categorized according to modified versions of the tools reported by Park. The implementation of an EMR system increased the direct nursing-care times for all nursing positions. However, the indirect nursing-care times of head nurses and nurse aids was lower, whereas that of registered nurses was higher, and the direct and indirect nursing-care times of RNs varied with the nursing unit and shift. The increases in direct nursing times, especially that spent by nurses providing descriptions and education to patients at their bedside, led to a global improvement in the nursing quality, and the indirect nursing times varied with the nursing position.

Classification of nursing statements based on the ICNP, the HHCC, and the nursing process for use in electronic nursing records.

The purposes of this study were to identify nursing-phenomena-related statements and nursing-action- related statements for use in nursing records, to link nursing statements for the nursing process, to develop integrated nursing terms using the ICNP, to identify new terms for inclusion, and to group statements using the HHCC in a user interface. We extracted 5,133 nursing-phenomena-related statements and 3,844 nursing-action-related statements, with the former including 233 nursing diagnoses. A total of 2791 nursing terms were mapped and 287 new terms were developed. Synonyms of 827 standard nursing terms were extracted. We developed trees of nursing statements using the HHCC for the user interface in an electronic nursing record. The quality of nursing documentation and the nursing performance improved with the standardization process.