Analysis of Standard Nursing Statement Recorded in Electronic Nursing Record (ENR) System in Kidney Transplant Patients

Abstract

Background and Purpose: The electronic nursing record (ENR), which includes a nursing process is an important data because it is the evidence of nursing care and nursing effect. Standard nursing statement is a template statement used in ENR system in many centers. But the frequency of standard nursing statement in ENR records, were not studied. The purpose of this study is to analyze the frequency of standard nursing statements used on ENR in kidney transplant (KT) patients. Material and methods: The Data were collected by retrospective review of ENR. 218 kidney transplant patients, whose transplantation was performed between Jan. 2010 and Dec. 2010 in a single center were enrolled. The nursing process statements, recorded in ENR system during admission for transplant surgery, were categorized by the International Classification for Nursing Practice (ICNP). This template was based on ICNP. Results: Total 291,674 nursing process statements were collected which means1337 statement per patients during 15days of admission. Diagnosis category was most frequent statement (33.9%). Five nursing diagnoses contents in the order of frequency were: risk for infection(12.55%), acute pain(11.9%), risk for impaired skin integrity(2.36%), ineffective tissue perfusion(1.77%), and deficient knowledge(1.61%). The greater part of nursing action statements were: assess for factor that increased the risk of infection, education and intervention for prevention of infection, and assessment of the pain. Standard nursing statements investigated the frequency of use as follows: standard nursing assessment statements(26.0%), standard nursing diagnosis statements(42.4%), standard nursing plan statements(26.5%), standard nursing intervention statements(36.2%), and standard nursing evaluation statements(21.6%). Discussion and conclusion: The main contents of ENR system in kidney transplant patient were prevention for infection, and pain management. Aside from these nursing care, succinct standardized nursing record guideline is needed specialized to kidney transplant patient. Education and further modification of standardized guidelines for the ideal nursing record, may be helpful in improving the quality of nursing records. This study will help nurses to perform their nursing processes more efficiently.