Electronic Nursing Record System Research Articles

Development of a Nursing Diagnosis/Record Generative AI System Based on Virtual Patient Data.

This study investigates how to reduce nurses' repetitive electronic nursing record tasks. We applied generative AI by learning nursing record data practiced with virtual patient data. We aim to evaluate generative AI's usefulness, usability, and availability when applied to nursing record creation tasks. The nursing record data collected through the electronic nursing record system for nursing students without privacy issues is in the form of NANDA, FocusDAR, SOAPIE, and narrative records. We trained 50,000 nursing record data and upgraded the performance through generative AI and fine-tuning. A separate API was used to connect with the practice electronic nursing record system, and 40 experienced nurses from a university hospital conducted tests. The electronic nursing record, through generative AI, is expected to contribute to easing the workload of nurses.

Development of a Cloud-Based Electronic Nursing Record System (ENR) for Nursing Student Practice.

The purpose of this study is to develop cloud-based electronic nursing records (ENR) that can be used as Academic-EMR to help students adapt to the clinical field and improve the clarity of nursing records and nursing information capabilities. This research and development are expected to increase the efficiency of nursing work in clinical sites by improving students' access to ENR through the development of various virtual patient contents.

Technological Competency As Caring in Nursing: a Description, Analysis and Evaluation of The Theory.

IntroductionWhen introducing and using technology in nursing, there is a danger that too much focus is placed on technology over caring for patients. The ‘Technological competency as caring in nursing’ theory can facilitate technology in caring, but the theory needs to be described, analysed and evaluated before it is used. The purpose of the literature review was to determine the possibility of applying the theory in education, research and practice, and whether the theory could be used to guide research into the use of electronic nursing record systems.MethodsA literature search was conducted in PubMed, CINAHL, ScienceDirect, Google Scholar and Google Books, and supplemented with manual searching using the keywords ‘Locsin’, ‘technology’, ‘caring’ and ‘nursing theory’. The criteria for inclusion were fully accessible articles and books in English on the relevant topics. The review process is shown in a PRISMA diagram. A hierarchy of evidence was used to evaluate the relative strength of the results. Pajnkihar’s model was used to describe, analyse and evaluate the theory.ResultsA total of 26 hits were included in the final analysis. The theory in question meets the criteria of clarity, simplicity and complexity, adequacy, importance and significance; it can be tested; and it is useful in patient care that employs technology.Discussion and conclusionThe theory is useful in nursing education, research and practice. The theory will be used to guide research on the perception of technological competency and care of internal medicine patients by nurses when using the electronic nursing record system in three Slovenian hospitals.

Pattern Analysis of Inpatient Falls in a Tertiary Hospital.

We analyzed the spatial and temporal patterns of inpatient falls in a tertiary hospital. Data were obtained from the adverse-event self-reporting system and the electronic nursing record system of the hospital. Through chart reviews we reclassified the cases. Most falls occurred by the bedside, followed by the restroom and hallway, and they occurred most often between 2 a.m. and 6 a.m. These findings indicate when and where nurses should be most alert about falls.

Peran Sicantik dalam Meningkatkan Kinerja Perawat di Rumah Sakit

The low ability of nurses in documenting nursing care as a result of limited human resources, too much writing format, differences in perceptions between nurses and the inability of nurses to enforce nursing diagnoses accurately will have an impact on the performance and service delivery to patients. This study aimed to fine out the nurse’s performance based on the characteristics of respondents and determine the effect of the application of the Si-Cantik application program (Electronic nursing record system) on the performance of nurses at the hospital. The research method used a one group pre-post test design approach with an intervention in the installation of an electronic nursing record system that is computer-based in the treatment room. The sampling technique used Simple random sampling with sample of 35 nurses. Statistical analysis using Chi-square test and Wilcoxon signed rank test. The results showed that the majority of respondents (77.14%) found it easy to apply the program, most nurses (77.68%) had good performance and statistically the implementation of the electronic nursing record system had an effect on nurses' performance in providing nursing care in hospitals (p = 0.004). The application of electronic nursing records system can be applied by nurses as supporting nurses' performance in providing nursing care in hospitals and becoming a reference in the use of digital nursing as an effort to develop self-potential so that they can carry out nursing services professionally.

Development and validation of detailed clinical models for nursing actions in perinatal care

ObjectivesThe aim of this study was to develop and evaluate detailed clinical models (DCMs) for nursing actions in perinatal care. We propose the use of action-target dyads as entities in DCMs for nursing actions. MethodsWe identified action and target concepts, attributes, and value sets by analyzing nursing documentation and reviewing the wider literature, in addition to published standards and models. We developed the DCMs by linking entities, attributes, and value sets. DCMs were classified by action type based on the Clinical Care Classification, and by target type based on the axes of the International Classification for Nursing Practice (ICNP). Attributes in the DCMs were also classified by ICNP axes. The quality of the DCMs was evaluated by domain experts, and their coverage was evaluated by mapping narrative nursing statements. ResultsNursing DCMs consisting of 233 entities (dyads comprising 34 action and 212 target concepts), 214 attributes and 541 values were developed. The most frequent action type was hands-on care (43.3%). The focus axis was used most frequently for the targets (51.9%) and attributes (38.8%). The quality scores of the DCMs ranged from 0.80 to 0.96. Most (174/192; 90.6%) of the statements were fully mapped, while 7 (3.7%) were partially mapped and 11 (5.7%) were not mapped. We modified the DCMs in accordance with these results. ConclusionsIn total, 240 DCMs were developed with action-target dyads as entities. The DCMs developed in this study could be implemented in an electronic nursing record system to enhance nursing practices and ensure semantic interoperability of nursing data.

간호학생의 교육용 전자간호기록 시스템 적용 효과

Purpose This study aimed to identify the effectiveness of educational Electronic Nursing Record System in terms of nursing process preparation ability and satisfaction about the system itself. Methods A one group pre-post experimental study design was utilized in this study. The effectiveness of the system was examined through quality of nursing diagnoses, interventions, and outcomes and electronic nursing record system satisfaction inventory. Junior and senior nursing students were the potential study respondents and evaluation instruments were applied only for the one who agreed to participated in the study. Education about nursing process and electronic nursing record system was carried out as part of regular classes and students were guided to prepare nursing process upon the scenarios developed earlier. Results 29 juniors and 33 seniors prepare nursing process documentation related to each scenario and both groups showed significant improvement upon nursing process documentation (t=7.53, p<.001, t=3.23, p=.003, respectively) compared to paper based nursing process preparation. Satisfaction about system itself was 2.78(0.81). Conclusion Educational electronic nursing record system seems to be effective to train nursing students for nursing process preparation ability. Effort to enhance its utility are called in the area of education and system itself. Keywords: Nursing records, Nursing students, Nursing process, Informatics, Personal satisfaction 주요어: ì „ìžê°„í˜¸ê¸°ë¡, 간호대학생, ê°„í˜¸ê³¼ì • ì ìš©ëŠ¥ë ¥, 이용 만족도

Comparing usability testing outcomes and functions of six electronic nursing record systems

ObjectivesThis study examined the usability of six differing electronic nursing record (ENR) systems on the efficiency, proficiency and available functions for documenting nursing care and subsequently compared the results to nurses' perceived satisfaction from a previous study. MethodsThe six hospitals had different ENR systems, all with narrative nursing notes in use for more than three years. Stratified by type of nursing unit, 54 staff nurses were digitally recorded during on-site usability testing by employing validated patient care scenarios and think-aloud protocols. The time to complete specific tasks was also measured. Qualitative performance data were converted into scores on efficiency (relevancy), proficiency (accuracy), and a competency index using scoring schemes described by McGuire and Babbott. Six nurse managers and the researchers completed assessments of available ENR functions and examined computerized nursing process components including the linkages among them. ResultsFor the usability test, participants' mean efficiency score was 94.2% (95% CI, 91.4–96.9%). The mean proficiency was 60.6% (95% CI, 54.3–66.8%), and the mean competency index was 59.5% (95% CI, 52.9–66.0). Efficiency scores were significantly different across ENRs as was the time to complete tasks, ranging from 226.3 to 457.2s (χ2=12.3, P=0.031; χ2=11.2, P=0.048). No significant differences were seen for proficiency scores. The coverage of the various ENRs' nursing process ranged from 67% to 100%, but only two systems had complete integration of nursing components. Two systems with high efficiency and proficiency scores had much lower usability test scores and perceived user satisfaction along with more complex navigation patterns. ConclusionsIn terms of system usability and functions, different levels of sophistication of and interaction performance with ENR systems exist in practice. This suggests that ENRs may have variable impacts on clinical outcomes and care quality. Future studies are needed to explore ENR impact on nursing care quality, efficiency, and safety.

The Development Of The Electronic Nursing Record System (ENRS) In The Hospital Setting: An Integrative Literature Review

In Indonesian hospitals, particularly in South Sulawesi Province, one of the activities that needs improvement by design is that of nursing records. This vital task is not completed due mainly to the fact that, incredibly, no model has been implemented to date mainly because of financial constraints and the overall lack of nurses’ computer literacy within the health services area in Indonesia. Although copious nursing recordkeeping is standard practice abroad, this vital task is not the norm in our area. Thus, the aim of this integrative literature review was to investigate the development of the electronic nursing record system (ENRS) in hospital settings across different countries and its effects on the care process and care outcomes. The results of this review showed that ENRS has been used widely in other developed countries and has benefited nurses and other healthcare providers. Hence, the findings of this review can be used by hospital policymakers in other developing countries, where the ENRS have not been implemented yet, as the evidence to consider the use of the ENRS.

Appropriateness of ICNP in Korean home care nursing

ObjectivesThere are several hospitals in Korea that introduced the ICNP (International Classification for Nursing Practice) as the standard terminology for clinical and home care nursing. This research attempted to determine the appropriateness of ICNP in Korean, hospital based, home care nursing. MethodsThe data was collected from a home care nursing center from January 1, 2009 to September 21, 2012. The center is operated by a Korean teaching hospital equipped with an ICNP based electronic nursing record (ENR) system. Via a refining process, 40,082 simplified sentences of nursing intervention were acquired from 41,158 nursing records. Among them, 545 preferred nursing statements were extracted, then mapped, to ICNP 2011 at both axis and sentence levels. ResultsThe mapping results were classified into three categories based on the axis of concept origin and the level of hierarchy. These categories were titled: complete, incomplete and no mapping. Out of 45 unique concepts in the action axis, 42 (93.33%) concepts were completely mapped. However, only 38 (15.08%), out of 252 unique concepts, were completely mapped in the focus axis. At the statement level, only 19.63% of statements were completely mapped. ConclusionsThe ICNP is not useful as a tool for home care nursing in its present form. The granularity of ICNP has to be improved and more concepts, specific to home care nursing, need to be added in the focus and action axes. Also, a new measure needs to be introduced to prevent information loss during mapping.

Identifying Usability Level and Factors Affecting Electronic Nursing Record Systems: A Multi-institutional Time-motion Approach

The usability, user satisfaction, and impact of electronic nursing record (ENR) systems were investigated. This mixed-method research was performed as a time-motion (TM) study and a survey which were carried out at six hospitals between August and November 2013. The TM study involved 108 nurses from medical, surgical, and intensive care units at each hospital, plus an additional 48 nurses who served as nonparticipating observers. In the survey, 1879 volunteer nurses completed the Impact of ENR Systems Scale, the System Usability Scale, and a global satisfaction scale. Qualitative and quantitative analyses were performed. The mean scores for the ENR impact, system usability, and satisfaction were 4.28 (out of 6), 58.62 (out of 100), and 74.31 (out of 100), respectively, and they differed significantly between hospitals (F=43.43, p<.001, F=53.08 and p<.001, and F=29.13 and p<.001, respectively). A workflow fragmentation assessment revealed different patterns of ENR system use among the included hospitals. Three user characteristics-educational background, practice period, and experience of using paper records-significantly affected the system usability and satisfaction scores. The system quality varied widely among the ENR systems. The generally low-to-moderate levels of system usability and user satisfaction suggest many opportunities for improvement.

Usability Testing and Comparison of Six Electronic Nursing Record Systems

Introduction/aims Nurses are rapidly converting to electronic nursing records (ENRs) due to the political, financial, and social needs both within and outside hospitals, and it is hoped that key quality benefits will be obtained from their adoption. Usability factors are a major issue for health information technology adoption, but little is known about the usability of ENR systems. The purpose of the study was to understand and determine the usability of ENR systems in terms of their efficiency and effectiveness. Methods/process/procedures The usability of a user-task system for laboratory function was evaluated. Six hospitals that have used different ENR systems (including narrative nursing records) for more than 3 years were recruited for this study. They were all academic tertiary hospitals in Korea with more than 1,000 beds and their own, self-developed ENR systems. Nine nurses from internal medicine wards, surgical wards, or intensive-care units were randomly selected from each hospital. Three paper-based clinical scenarios (appropriate to the ward/unit) and scoring criteria developed by the researchers were used. The 54 nurses were asked to imagine that they were taking care of a patient and to create a narrative nursing note with the hospital’s ENR system. They were also asked to vocalize what they were thinking while using the system. The user-system interactions were recorded digitally, classified into three categories, and scored by two researchers as follows: +1 (optimal), 0 (correct, but not optimal), and 1 (incorrect or failure). The scores were used to calculate the efficiency (the ratio of summing the total number of positive entries divided by the total number of all entries made), effectiveness (the ratio of the number of points earned divided by the maximum number of points), and competency index (combination of the efficiency and effectiveness scores into one index). The time taken to complete the task was also measured. Data were collected between June 2013 and October 2013 after acquiring permission from the institutional research review board at each hospital. Descriptive statistics and variance analysis were used to compare the systems. Results The mean number of entries was 12.4 sentences (range, 5-22 sentences). The overall efficiency of the six hospital ENR systems was 94.2% (95% CI, 91.4-96.9%; range, 84.3-99.3%). The differences between the systems were statistically significant (2=12.3, P=0.030). The mean effectiveness was 60.6% (95% CI, 54.3-66.8%; range, 42.8-66.6%). The competency indexes ranged from 42.4% to 50.0%, and the mean index was 47.4% (95% CI, 46.0-48.8). The nurses took a mean of 317 sec (95% CI, 273.7-360.8 sec) to complete the task; the time taken ranged significantly according to the system, from 226.3 to 457.2 sec (2=11.2, P=0.048). Discussion/outcomes The six ENR systems exhibited a high degree of efficiency and moderate-to-low effectiveness in terms of usability. Improvements in the quality of data entry are required for all of the six tested systems. Several of the systems require efforts to improve their efficiency and the user-system interactions to reduce the time required to complete a narrative nursing record.

유-헬스케어 기반 실시간 혈압, 혈당 측정치 전송의 간호기록 시간 단축

Purpose: The aim was to measure the real-time trans-mission effect of blood-pressure and blood-glucose value based on u-healthcare for saving the time and effort of nursing recording time. Methods: This study used a u-healthcare system based on the international standards for the exchange of health information. In order to verify the effectiveness of the u-healthcare, a clinical trial for the system regarding blood-pressure and blood-glucose targeting of patients with endocrine disorders at KNUH from February 7 to 9, 2012 was performed. Results: According to the analyzed results, of the 86 times the 11 patients were tested, measuring blood-pressure and blood-glucose using the u-healthcare system, we found the time differences between the real-time transfer recording method and existing hospital records that were used in the hospital. Based on the average time interval, there was a difference of 1,090.45 seconds (18.17 minutes). Conclusion: Therefore, it’s cumbersome that nurses in the hospital have to record the numerical values of the measured blood-pressure and blood-glucose manually and input the recorded values directly into the electronic nursing record system. However, it was found in terms of the newly designed system, that it could save time and effort for nurses, since measured information is sent to the hospital information system on a real-time basis.

HIR Collaborating with the CODATA Conference

HIR Collaborating with the CODATA Conference

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

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.

Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System

ObjectivesThe purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care.MethodsThis study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system.ResultsWe first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation.ConclusionsThe prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.

Exploring practice variation in preventive pressure-ulcer care using data from a clinical data repository

Objective The aims of this study were to explore pressure ulcer incidences and practice variations in the nursing intervention provided for preventive pressure-ulcer care to patients either with pressure ulcers or at risk of pressure ulcers, and to examine them in relation to the patients’ medical problems and the characteristics of the nurses who cared for them. Methods The narrative nursing notes of 427 intensive-care patients who were discharged in 2007 that were documented at the point-of-care using standardized nursing statements were extracted from a clinical data repository at a teaching hospital in Korea and analyzed. The frequencies of five nursing interventions for pressure-ulcer prevention were compared between pressure-ulcer and pressure-ulcer risk groups, as were the characteristics of the nurses who were treating the patients in these two groups. Nursing interventions for pressure-ulcer prevention were also assessed relative to the patients’ medical problems. Results The overall incidence of pressure ulcers was 15.0%. Position change was the most popular nursing intervention provided for pressure-ulcer prevention in both the pressure-ulcer and at-risk groups, followed by skin care. There was a statistically significant tendency toward a greater frequency of providing skin care and nutritional care in the at-risk group than in the pressure-ulcer group. There was no statistically significant difference in the mean frequencies of nursing interventions relative to the patients’ medical problems in the pressure-ulcer group. However, frequencies of nursing interventions did differ significantly between patients with neurological problems and those with other medical problems in the at-risk group. Analysis of the nurses’ characteristics revealed that more nursing interventions were documented by those who were younger, less experienced, and more educated. Conclusion A standardized nursing-terminology-based electronic nursing record system allowed us to monitor the variations in nursing practice with regard to preventive pressure-ulcer care in intensive-care patients with and at risk of pressure ulcers. We found that pressure-ulcer prevention care was provided at frequencies much lower than the recommended guidelines. Further studies on identifying the factors affecting pressure-ulcer prevention care and ways to improve the quality of that care are needed.

A Basic Study on Application of Voice Recognition Input to an Electronic Nursing Record System -Evaluation of the Function as an Input Interface-

As computerization in the nursing field has been recently progressing, an electronic nursing record system is gradually introduced in the medical institution in Japan. Although it is expected for the electronic nursing record system to reduce the load of nursing work, the conventional keyboard operation is used for information input of the present electronic nursing record system and it has some problems concerning the input time and the operationability for common nurses who are unfamiliar with the computer operation. In the present study, we conducted a basic study on application of voice recognition input to an electronic nursing record system. The voice input is recently introduced to an electronic medical record system in a few clinics. However, so far the entered information cannot be processed because the information of the medical record must be entered as a free sentence. Therefore, we contrived a template for an electronic nursing record system and introduced it to the system for simple information entry and easy processing of the entered information in this study. Furthermore, an input experiment for evaluation of the voice input with the template was carried out by voluntary subjects for evaluation of the function as an input interface of an electronic nursing record system. The results of the experiment revealed that the input time by the voice input is obviously fast compared with that by the keyboard input and operationability of the voice input was superior to the keyboard input although all subjects had inexperience of the voice input. As a result, it was suggested our method, the voice input using the template made by us, might be useful for an input interface of an electronic nursing record system.

Development of a nursing practice guideline for pre and post-operative care of gastric cancer patients.

ObjectivesThe aim of this study was to develop nursing practice guidelines and algorithms for the pre- and postoperative care of gastric cancer patients.MethodsThe guidelines and algorithms were developed based on a literature review and subject-matter experts' knowledge. The usefulness and applicability of the developed guidelines and algorithms were evaluated by the expert group.ResultsThe guidelines comprised 64 recommendations and algorithms for admission care, preoperative care on the day before the operation, preoperative care on the operation day, immediate postoperative assessment, postoperative care, and discharge care of gastric cancer patients. After appropriate evaluation, the experts declared the guidelines to be both useful and applicable.ConclusionsThe guidelines developed in this study can be used for patient care and for training nursing students and novice nurses. In addition, these guidelines can be integrated into the electronic nursing record system for clinical decision support in the future. This will improve the quality of clinical nursing and the expertise of nurses.

Developing an Electronic Nursing Record System for Clinical Care and Nursing Effectiveness Research in a Korean Home Healthcare Setting

Increased accountability requirements for the cost and quality of healthcare force nurses to clearly define and verify nursing's contributions to patient outcomes. This demand necessitates documentation of nursing care in a precise manner. An electronic nursing record system is considered a key element that enhances nurses' ability not only to record nursing care provided to patients but also to measure, report, and monitor quality and effectiveness. Home care is a growing field as nurses attempt to meet the demand for long-term care. The development of an electronic record system for home care nursing was the immediate focus of this study. We identified the nursing content required for home care nursing using standardized nursing languages and designed linkages among medical diagnoses, nursing diagnoses, nursing interventions, and nursing-sensitive outcomes within the system. Equipping an electronic nursing record system with nursing standards is particularly critical for enhancing nursing practice and for creating refined data to verify nursing effectiveness.