A Nursing‐Specific Model of EPR Documentation: Organizational and Professional Requirements

Abstract

To present the Norwegian documentation KPO model (quality assurance, problem solving, and caring). To present the requirements and multiple electronic patient record (EPR) functions the model is designed to address. The model's professional substance, a conceptual framework for nursing practice is developed by examining, reorganizing, and completing existing frameworks. The model's methodology, an information management system, is developed using an expert group. Both model elements were clinically tested over a period of 1 year. The model is designed for nursing documentation in step with statutory, organizational, and professional requirements. Complete documentation is arranged for by incorporating the Nursing Minimum Data Set. A systematic and comprehensive documentation is arranged for by establishing categories as provided in the model's framework domains. Consistent documentation is arranged for by incorporating NANDA-I Nursing Diagnoses, Nursing Intervention Classification, and Nursing Outcome Classification. The model can be used as a tool in cooperation with vendors to ensure the interests of the nursing profession is met when developing EPR solutions in healthcare. The model can provide clinicians with a framework for documentation in step with legal and organizational requirements and at the same time retain the ability to record all aspects of clinical nursing.