J Korean Acad Fundam Nurs.  2024 Nov;31(4):396-409. 10.7739/jkafn.2024.31.4.396.

Experiences of Recording Electronic Nursing Notes among Ward Nurses in Two Hospitals

• Hwang H
• Kim GH
• Song Y

• KMID: 2561807
• DOI: http://doi.org/10.7739/jkafn.2024.31.4.396

Abstract

Purpose
This study explored the experiences of recording electronic nursing notes among ward nurses in the hospital.
Methods
A qualitative descriptive study was conducted. Data were collected through in-depth interviews with 15 nurses at two university hospitals in Daegu between November 2022 and April 2023. Hsieh and Shannon’s conventional content analysis method was applied, and MAXQDA was used for the analysis.
Results
Three categories were identified from the data, with 12 subcategories and 46 codes. The three categories were as follows: utility, limitations to effective use, and seeking a way to expand functions efficiently.
Conclusion
Records involving electronic nursing notes played a very important role in patient care and legal protection, as well as serving as a guide to nursing diagnosis, a source of pride, and a resource with convenient functions. Areas for improvement relate to awareness, burden, discomfort, disparities, and obstacles to record-keeping. A more efficient record system needs to be established, with corresponding education. Furthermore, hospital administrators should provide policy support to improve the quality of nursing records.

Keyword

Electronic health records; Nurses; Nursing; Qualitative research; 전자간호기록, 간호, 간호사, 질적연구