International Journal of Medical Informatics
Volume 79, Issue 8 , Pages 554-564 , August 2010

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

  • Kristiina Häyrinen

      Affiliations

    • Department of Health and Social Management, University of Eastern Finland (Kuopio Campus), Savilahdentie 6 A 3krs., P.O. Box 1627, FIN-70211 Kuopio, Finland
    • Corresponding Author InformationCorresponding author. Tel.: +358 407082500.
    • ,
  • Johanna Lammintakanen

      Affiliations

    • Department of Health and Social Management, University of Eastern Finland (Kuopio Campus), Finland
    • ,
  • Kaija Saranto

      Affiliations

    • Department of Health and Social Management, University of Eastern Finland (Kuopio Campus), Finland

Received 18 June 2009 ,Revised 11 April 2010 ,Accepted 9 May 2010.

References 

  1. ISO/TR 20514, Health Informatics – Electronic Health Record – Definition, Scope, and Context 2005. Available from: http://www.openehr.org/downloads/standards/iso/isotc215wg3_N202_ISO-TR_20514_Final_%5B2005-01-31%5D.pdf. 22.01.2010.
  2. Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Database Syst. Rev. 2009;(1):Art. No.: CD002099.pub2
  3. Ammenwerth E, Eichstadter R, Haux R, Pohl U, Rebel S, Ziegler S. A randomized evaluation of a computer-based nursing documentation system. Methods Inf. Med. 2001;40(May (2)):61–68
  4. Mahler C, Ammenwerth E, Wagner A, Tautz A, Happek T, Hoppe B, et al. Effects of a computer-based nursing documentation system on the quality of nursing documentation. J. Med. Syst. 2007;31(August (4)):274–282
  5. Häyrinen K, Saranto K, Nykänen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int. J. Med. Inform. 2008;77(May (5)):291–304
  6. Saranto K, Kinnunen UM. Evaluating nursing documentation—research designs and methods: systematic review. J. Adv. Nurs. 2009;65(March (3)):464–476
  7. Yura H, Walsh M. The Nursing Process: Assessing, Planning, Implementing, Evaluating. third ed.. New York: Appleton-Century-Crofts; 1978;
  8. Pryor TA. Computerized nurse charting. Int. J. Clin. Monit. Comput. 1989;6(July (3)):173–179
  9. Holzemer WL, Henry SB. Computer-supported versus manually-generated nursing care plans: a comparison of patient problems, nursing interventions, and AIDS patient outcomes. Comput. Nurs. 1992;10(January–February (1)):19–24
  10. Larrabee JH, Boldreghini S, Elder-Sorrells K, Turner ZM, Wender RG, Hart JM, et al. Evaluation of documentation before and after implementation of a nursing information system in an acute care hospital. Comput. Nurs. 2001;19(March–April (2)):56–65quiz 66-8
  11. Daly JM, Buckwalter K, Maas M. Written and computerized care plans, organizational processes and effect on patient outcomes. J. Gerontol. Nurs. 2002;28(September (9)):14–23
  12. Björvell C, Wredling R, Thorell-Ekstrand I. Long-term increase in quality of nursing documentation: effects of a comprehensive intervention. Scand. J. Caring Sci. 2002;16(March (1)):34–42
  13. Ehrenberg A, Birgersson C. Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district. Scand. J. Caring Sci. 2003;17(September (3)):278–284
  14. Ehnfors M, Florin J, Ehrenberg A. Applicability of the international classification of nursing practice (ICNP) in the areas of nutrition and skin care. Int. J. Nurs. Terminol. Classif. 2003;14(January–March (1)):5–18
  15. Törnvall E, Wilhelmsson S, Wahren LK. Electronic nursing documentation in primary health care. Scand. J. Caring Sci. 2004;18(September (3)):310–317
  16. Törnvall E, Wahren LK, Wilhelmsson S. Impact of primary care management on nursing documentation. J. Nurs. Manag. 2007;15(September (6)):634–642
  17. Averill CB, Marek KD, Zielstorff R, Kneedler J, Delaney C, Milholland DK. ANA standards for nursing data sets in information systems. Comput. Nurs. 1998;16(May–June (3)):157–161
  18. Henry SB, Mead CN. Nursing classification systems: necessary but not sufficient for representing “What Nurses Do” for inclusion in computer-based patient record systems. J. Am. Med. Inform. Assoc. 1997;4(May–June (3)):222–232
  19. Henry SB, Warren JJ, Lange L, Button P. A review of major nursing vocabularies and the extent to which they have the characteristics required for implementation in computer-based systems. J. Am. Med. Inform. Assoc. 1998;5(July–August (4)):321–328
  20. Hardiker NR, Hoy D, Casey A. Standards for nursing terminology. J. Am. Med. Inform. Assoc. 2000;7(November–December (6)):523–528
  21. Dochterman J, Titler M, Wang J, Reed D, Pettit D, Mathew-Wilson M, et al. Describing use of nursing interventions for three groups of patients. J. Nurs. Scholarsh. 2005;37(1):57–66
  22. Delaney C, Reed D, Clarke M. Describing patient problems & nursing treatment patterns using nursing minimum data sets (NMDS & NMMDS) & UHDDS repositories. Proc. AMIA Symp. 2000;176–179
  23. Park M, Delaney C, Maas M, Reed D. Using a nursing minimum data set with older patients with dementia in an acute care setting. J. Adv. Nurs. 2004;47(August (3)):329–339
  24. Smith K, Smith V, Krugman M, Oman K. Evaluating the impact of computerized clinical documentation. Comput. Inform. Nurs. 2005;23(May–June (3)):132–138
  25. Goossen WT, Epping PJ, Dassen T. Criteria for nursing information systems as a component of the electronic patient record. An international Delphi study. Comput. Nurs. 1997;15(November–December (6)):307–315
  26. Brender J, Nohr C, McNair P. Research needs and priorities in health informatics. Int. J. Med. Inform. 2000;58-59(September):257–289
  27. Grimson J. Delivering the electronic healthcare record for the 21st century. Int. J. Med. Inform. 2001;64(December (2–3)):111–127
  28. van Ginneken AM. The computerized patient record: balancing effort and benefit. Int. J. Med. Inform. 2002;65(June (2)):97–119
  29. Evers G, Viane A, Sermeus W, Simoens-De Smet A, Delesie L. Frequency of and indications for wholly compensatory nursing care related to enteral food intake: a secondary analysis of the Belgium National Nursing Minimum Data Set. J. Adv. Nurs. 2000;32(July (1)):194–201
  30. Prophet CM. The evolution of a clinical database: from local to standardized clinical languages. Proc. AMIA Symp. 2000;660–664
  31. Goossen WT, Epping PJ, Feuth T, van den Heuvel WJ, Hasman A, Dassen TW. Using the nursing minimum data set for the Netherlands (NMDSN) to illustrate differences in patient populations and variations in nursing activities. Int. J. Nurs. Stud. 2001;38(June (3)):243–257
  32. Griens AM, Goossen WT, Van der Kloot WA. Exploring the nursing minimum data set for the Netherlands using multidimensional scaling techniques. J. Adv. Nurs. 2001;36(October (1)):89–101
  33. Goossen WT. Statistical analysis of the nursing minimum data set for the Netherlands. Int. J. Med. Inform. 2002;68(December (1–3)):205–218
  34. Tanttu K, Ikonen H. Nationally standardized electronic nursing documentation in Finland by the year 2007. Stud. Health Technol. Inform. 2006;122:540–541
  35. Saba VK. Nursing classifications: home health care classification system (HHCC): an overview. Online J. Issues Nurs. 2002;7(3):9
  36. McCormick KA, Lang N, Zielstorff R, Milholland DK, Saba V, Jacox A. Toward standard classification schemes for nursing language: recommendations of the American Nurses’ Association Steering Committee on databases to support clinical nursing practice. J. Am. Med. Inform. Assoc. 1994;1(November–December (6)):421–427
  37. Fagerström L, Rainio AK, Rauhala A, Nojonen K. Validation of a new method for patient classification, the Oulu patient classification. J. Adv. Nurs. 2000;31:481–490
  38. K. Tanttu, From free text to standardized nursing language—the national development project of nursing documentation in Finland, IT @ NETWORKING COMMUNICATIONS, Volume 3/Issue 1, ISSN 1784-0716/December 2009–April 2010. http://hitm.eu/downloads/IT@09_Review.pdf. 11.4.2010.
  39. Ensio A, Saranto K, Ikonen H, Iivari A. The national evaluation of standardized terminology. Stud. Health Technol. Inform. 2006;122:749–752
  40. Werley HH, Devine EC, Zorn CR, Ryan P, Westra BL. The nursing minimum data set: abstraction tool for standardized, comparable, essential data. Am. J. Public Health. 1991;81(April (4)):421–426
  41. Jokinen T, Ensio A, Saranto K. Using standardized terminology for nursing documentation. Stud. Health Technol Inform. 2006;122:995
  42. K. Remes, Structured Documentation in Nursing Discharge Summaries [Master's thesis on the Internet], University of Kuopio, 2006. Available from: http://www.uku.fi/tht/opinnaytteet/kmremesgradu.pdf. 22.01.2010.
  43. Saranto K, Ensio A, Jokinen T. Patient medication—how is it documented?. Stud. Health Technol Inform. 2006;122:738–741
  44. U.M. Kinnunen, Structured Data in the Wound Care Documentation, Master's Thesis, University of Kuopio, 2007. Available from: http://www.uku.fi/tht/opinnaytteet/UMKinnunengradu.pdf. 22.01.2010.
  45. Ammenwerth E, de Keizer N. An inventory of evaluation studies of information technology in health care. Trends in evaluation research 1982–2002. Methods Inf. Med. 2005;44(1):44–56
  46. Müller-Staub M, Lavin MA, Needham I, van Achterberg T. Nursing diagnoses, interventions and outcomes—application and impact on nursing practice: systematic review. J. Adv. Nurs. 2006;56(December (5)):514–531
  47. Ehnfors M, Smedby B. Nursing care as documented in patient records. Scand. J. Caring Sci. 1993;7(4):209–220
  48. Björvell C, Thorell-Ekstrand I, Wredling R. Development of an audit instrument for nursing care plans in the patient record. Qual. Health Care. 2000;9(March (1)):6–13
  49. Nahm R, Poston I. Measurement of the effects of an integrated, point-of-care computer system on quality of nursing documentation and patient satisfaction. Comput. Nurs. 2000;18(September–October (5)):220–229
  50. Hellesø R. Information handling in the nursing discharge note. J. Clin. Nurs. 2006;15(January (1)):11–21
  51. Müller-Staub M, Lunney M, Lavin MA, Needham I, Odenbreit M, van Achterberg T. Testing the Q-DIO as an instrument to measure the documented quality of nursing diagnoses. Interventions, and outcomes. Int. J. Nurs. Terminol. Classif. 2008;19(January–March (1)):20–27

PII: S1386-5056(10)00098-5

doi: 10.1016/j.ijmedinf.2010.05.002

International Journal of Medical Informatics
Volume 79, Issue 8 , Pages 554-564 , August 2010

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