TY - JOUR
T1 - Reinterpreting the nursing record for an electronic context
AU - Hardiker, Nicholas
AU - Dowding, Dawn
AU - Dykes, Patricia C.
AU - Sermeus, Walter
PY - 2019/7/1
Y1 - 2019/7/1
N2 - Background: This article seeks to facilitate the re-imagining of nursing records purposefully within an electronic context. It questions existing approaches to nursing documentation, critically examines existing nursing record systems and identifies new requirements. Methods: A comprehensive literature review was conducted to identify themes, that might meaningfully contribute to a new approach to nursing record systems development, around four key interrelated areas – standards, decision making, abstraction and summarization, and documenting. Studies were analyzed using narrative synthesis to provide a critical analysis of the current ‘state of the art’, and recommendations for the future. Results: Included studies collectively described aspects of current best practice, both in terms of nursing record systems themselves, and how nurses and other health professionals contribute to and engage with those systems. A number of cross-cutting themes identified more novel approaches taken by nurses to systems development: going back to basics in determining purpose; firming up informatics foundations; nuancing or tailoring to suit different requirements; and engagement, involvement and participation. Conclusion: There is a paucity of research that specifically focuses on the nature of the electronic nursing record and its impact on patient care processes and outcomes. In addition to further research in these areas, there is a need: to reinterpret nurses as knowledge workers rather than as ‘data collectors’; to agree on the application in practice of appropriate standards and terminologies; and to work together with system developers to change the ways in which data are captured and care is documented.
AB - Background: This article seeks to facilitate the re-imagining of nursing records purposefully within an electronic context. It questions existing approaches to nursing documentation, critically examines existing nursing record systems and identifies new requirements. Methods: A comprehensive literature review was conducted to identify themes, that might meaningfully contribute to a new approach to nursing record systems development, around four key interrelated areas – standards, decision making, abstraction and summarization, and documenting. Studies were analyzed using narrative synthesis to provide a critical analysis of the current ‘state of the art’, and recommendations for the future. Results: Included studies collectively described aspects of current best practice, both in terms of nursing record systems themselves, and how nurses and other health professionals contribute to and engage with those systems. A number of cross-cutting themes identified more novel approaches taken by nurses to systems development: going back to basics in determining purpose; firming up informatics foundations; nuancing or tailoring to suit different requirements; and engagement, involvement and participation. Conclusion: There is a paucity of research that specifically focuses on the nature of the electronic nursing record and its impact on patient care processes and outcomes. In addition to further research in these areas, there is a need: to reinterpret nurses as knowledge workers rather than as ‘data collectors’; to agree on the application in practice of appropriate standards and terminologies; and to work together with system developers to change the ways in which data are captured and care is documented.
KW - Decision support systems
KW - Electronic health record
KW - Nursing
KW - Quality indicators
KW - Requirements
KW - Terminology
KW - User-computer interface
UR - http://www.scopus.com/inward/record.url?scp=85064995653&partnerID=8YFLogxK
U2 - 10.1016/j.ijmedinf.2019.04.021
DO - 10.1016/j.ijmedinf.2019.04.021
M3 - Article
VL - 127
SP - 120
EP - 126
JO - International Journal of Medical Informatics
JF - International Journal of Medical Informatics
SN - 1386-5056
ER -