Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing

Abstract 

Purpose

The purpose of this study was to describe and evaluate whether nurses have documented patient care in compliance with the national nursing documentation model in electronic health records, which means the use of the nursing process and the use of standardized terminology in different phases of the nursing process.

Methods

The data were collected from a central hospital in 2003–2006. The data consist of the electronic nursing care plans of 67 neurological patients and 422 surgical patients. The data were analyzed using statistical methods and content analysis.

Results

Standardized electronic nursing documentation is based on the nursing process, although the use of the nursing process varies across patients. There is a lack of progress notes relating to needs assessment, the identification of nursing diagnoses and care aims, and the nursing interventions planned in the documentation. The standardized terminology is used in the documentation but inconsistencies emerge in the use of the different classifications.

Conclusion

The national model for electronic nursing documentation is suitable for the documentation of patient care in nursing care plans. However, health care professionals need further training in documenting patient care according to the nursing process, and in using the terminology in order to increase patient safety and improve documentation.

Keywords: Nursing documentation, Terminology, Classification, Medical records, Computerized, Evaluation