J Korean Soc Med Inform.  1998 Dec;4(2):69-79.

Analysis and Standardization of Nursing Record Forms for Nursing Informatics Standard

• Park HA
• Cho IS
• Kim KD
• Kim SH
• Park JS
• Lee YS
• Yoo KS
• Jung YL
• Choi WJ
• Han JR

Abstract

This paper reflects on the standardization activities of nursing documentation. Even though nurses are the most important manpower in terms of collecting patients' data, nursing documentation have been overlooked in the process of developing electronic patients records. It is impossible to complete a computerized patient record system without including nursing documentation. Standardization of nursing documentation is the first step toward a computerized documentation system. In this study nursing documentation forms were gathered from 11 tertiary hospital with more than 500 beds in Seoul. Out of various nursing documentation, 9 essential forms were chosen to standardize. They are admission assessment, form, nursing treatment record, nursing care plan, discharge planning record, patient transfer record, clinical observation record, nursing treatment record, nursing progress notes, critical care flow sheet, and preoperative checklist Forms and data elements were reviewed and analyzed. It was learned that there is no one perfect from that could be used in any agency. Data elements were analyzed and standardized. Data elements to be included in each form were selected. Standardized forms were developed with the selected data element. Guideline outlining how to use each nursing form were developed. Now it is in the process of validating the forms and the guidelines at 240 nursing units at 8 tertiary hospitals. The results of the validation study will be incorporated in the final version of nursing forms and they will be introduced to general nursing population at an open forum to be held by Korean Nurses Association at the end of this year. This standardization activities will have a great impact on nursing practice, education, administration and research.

Keyword

Standardization; Nursing Information Standardization; Nursing Record Form; Nursing Record Items; Nursing Data

MeSH Terms

Checklist
Critical Care
Education
Health Records, Personal
Humans
Nursing Informatics*
Nursing Records*
Nursing*
Patient Discharge
Patient Transfer
Seoul
Tertiary Care Centers