Healthc Inform Res.  2012 Jun;18(2):136-144. 10.4258/hir.2012.18.2.136.

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

• Park HA
• Min YH
• Jeon E
• Chung E

• KMID: 2045577
• DOI: http://doi.org/10.4258/hir.2012.18.2.136

Abstract

OBJECTIVES
The 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.
METHODS
This 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.
RESULTS
We 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.
CONCLUSIONS
The 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.

Keyword

Computerized Medical Record Systems; Nursing Records; Evidence-Based Practice; Concept Formation; Semantics

MeSH Terms

Concept Formation
Electronics
Electrons
Evidence-Based Practice
Medical Records Systems, Computerized
Nursing Assessment
Nursing Records
Perinatal Care
Semantics

Figure

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  Figure 1 Development phase of an electronic nursing record system based on detailed clinical models and clinical practice guidelines. ICNP: the International Classification for Nursing Practice.

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  Figure 2 Generating nursing statements using the 'labor pain' detailed clinical model.

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  Figure 3 Nursing statement set of intrapartum care for vaginal delivery.

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  Figure 4 Elements of the electronic nursing record system based on detailed clinical models and clinical practice guidelines. ICNP: the International Classification for Nursing Practice. DCM: detailed clinical models.

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  Figure 5 Screenshot of the electronic nursing record system based on detailed clinical models and clinical practice guidelines.

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