Abstract
BackgroundNursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context.MethodsA four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of the MDS. Then, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Afterward, the ECNDS was developed according to the finalized MDS, and eventually, its performance was evaluated by involving the end-users.ResultsThe proposed MDS was divided into administrative and clinical sections; including nursing assessment and the nursing diagnosis process. Then, a web-based system with modular and layered architecture was developed based on the derived MDS. Finally, to evaluate the developed system, a survey of 150 registered nurses (RNs) was conducted to identify the positive and negative impacts of the system.ConclusionsThe developed system is suitable for the documentation of patient care in nursing care plans within a legal, ethical, and professional framework. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.
Highlights
Nursing documentation is a critical aspect of the nursing care workflow
It has been revealed that employing an electronic medical record (EMR) and electronic clinical nursing documentation leads to higher quality, more complete, and more patient-centric documentation than manual nursing documentation
The minimum data set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of Minimum Data Set (MDS)
Summary
Nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context. One-half of all nurses must stay at work for 1–2 h after the end of their shifts, mainly to complete nursing records [13] This approach has several drawbacks including wasted time, disruption in patient care, medical errors, endangering patients’ safety, fading and illegibility of the paperwork, high staff turnover rates, legal problems, and, other similar factors [14, 15]. Due to the fast developments in information technology, the health industry actively attempts to employ electronic medical records (EMRs) for clinical practice, research, education, and supervision purposes. The purpose of this study was to design, develop, and evaluate of an electronic clinical nursing documentation System (ECNDS) and determine its core data elements and the validity of their corresponding values
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