Nursing record systems

effects on nursing practice and healthcare outcomes

Christine Urquhart, Rosemary Currell, Maria J Grant, Nicholas R Hardiker

Research output: Contribution to journalArticle

86 Citations (Scopus)

Abstract

Background
A nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.

Objectives
To assess the effects of nursing record systems on nursing practice and patient outcomes.

Search methods
For the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.

Selection criteria
Randomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.

Data collection and analysis
Two review authors (in two pairs) independently assessed trial quality and extracted data.

Main results
We included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.

Authors' conclusions
We found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi-experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.
Original languageEnglish
Number of pages67
JournalThe Cochrane Library
DOIs
Publication statusPublished - Jan 2009
Externally publishedYes

Fingerprint

Nursing Records
Nursing
Nurses
Delivery of Health Care
Nursing Informatics
Allied Health Personnel
Nursing Research
Qualitative Research
Pain Management
Nursing Care
Information Systems
MEDLINE
Caregivers
Pregnant Women
Primary Health Care
Patient Care
Research Design
Parents
Organizations
Students

Cite this

@article{b5004b3e49f8403e8fd13749fb304114,
title = "Nursing record systems: effects on nursing practice and healthcare outcomes",
abstract = "BackgroundA nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.ObjectivesTo assess the effects of nursing record systems on nursing practice and patient outcomes.Search methodsFor the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.Selection criteriaRandomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.Data collection and analysisTwo review authors (in two pairs) independently assessed trial quality and extracted data.Main resultsWe included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.Authors' conclusionsWe found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi-experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.",
author = "Christine Urquhart and Rosemary Currell and Grant, {Maria J} and Hardiker, {Nicholas R}",
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publisher = "John Wiley and Sons Ltd",

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Nursing record systems : effects on nursing practice and healthcare outcomes. / Urquhart, Christine; Currell, Rosemary; Grant, Maria J; Hardiker, Nicholas R.

In: The Cochrane Library, 01.2009.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Nursing record systems

T2 - effects on nursing practice and healthcare outcomes

AU - Urquhart, Christine

AU - Currell, Rosemary

AU - Grant, Maria J

AU - Hardiker, Nicholas R

PY - 2009/1

Y1 - 2009/1

N2 - BackgroundA nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.ObjectivesTo assess the effects of nursing record systems on nursing practice and patient outcomes.Search methodsFor the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.Selection criteriaRandomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.Data collection and analysisTwo review authors (in two pairs) independently assessed trial quality and extracted data.Main resultsWe included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.Authors' conclusionsWe found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi-experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.

AB - BackgroundA nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.ObjectivesTo assess the effects of nursing record systems on nursing practice and patient outcomes.Search methodsFor the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.Selection criteriaRandomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.Data collection and analysisTwo review authors (in two pairs) independently assessed trial quality and extracted data.Main resultsWe included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.Authors' conclusionsWe found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi-experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.

U2 - 10.1002/14651858.CD002099.pub2

DO - 10.1002/14651858.CD002099.pub2

M3 - Article

JO - The Cochrane Library

JF - The Cochrane Library

ER -