Comparison of Nursing Records of Open Heart Surgery Patients before and after Implementation of Electronic Nursing Record / 대한의료정보학회지

OBJECTIVES: The objective of this study is to compare nursing records before and after the implementation of an electronic nursing records system. METHODS: Twenty patients' paper-based nursing records and 20 patients' electronic nursing records were analyzed according to the nursing process and compared in terms of quantity and quality. RESULTS: In terms of quantity, the average number of statements documented per patient per day has increased by 2.5 times, from 10.3 to 25.6 statements. The average number of redundancies of a unique statement also has increased by 67%, from 5.0 to 8.8. As for the content of nursing records, paper-based nursing records have more patient problem statements describing signs and symptoms, nursing observations, and patient status. Electronic nursing records have more nursing activity statements. In terms of quality, there were more nursing records following patterns of nursing process in electronic nursing records than paper-based nursing records. The electronic nursing records have a more detailed documentation compared to the paper-based nursing records. CONCLUSION: After the implementation of electronic nursing record system, quantity of nursing records and the pattern of nursing records following the nursing process have been increased and granularity of nursing records has been improved.

Analysis of Nursing Activity in General Hospital Using Hospital Information System / 대한의료정보학회지

OBJECTIVES: This study intended to identify the staff nurse's activity in general hospital, where its Hospital Information System is well established and Electronic Nursing Record System was being used for 2 years. METHODS: Procedure was done with the following steps; In the first step, nursing activity time was analysed by checklist, which 28 nurses filled out by themselves. The group interview was followed. RESULTS: During the day shift, the direct nursing activities took 37.04%, indirect nursing 40.74%, ward management 18.52% and personal time 3.70% respectively. In evening shift, nurses used 29.41% on direct nursing, 45.10% on indirect nursing, 19.61% on ward management and 5.88% on personal time. In night shift, direct nursing took 17.91%, indirect nursing 46.27%, ward management 17.91% and personal time 11.98%. The group interview reported the differences in nursing activities which recognized by the included staff nurses after the introduction of ENR; speed and convenience in working, the correctness and speed of recording, reduction of indirect nursing time including recording time and increase of direct nursing time and patient education. CONCLUSIONS: The introduction of HIS including ENR system was verified to be effective on improvement of nursing quality, by bringing reduction of indirect nursing time and increase of direct nursing time.

Formative Evaluation of Standard Terminology-based Electronic Nursing Record System in Clinical Setting / 대한의료정보학회지

The Objectives of this study are to evaluate the user satisfaction and actual data input time through an enterprise ICNP-based electronic nursing record system using the controlled vocabulary in a secondary care hospital (BSNUH). Study design is a formative evaluation using the QUIS (Questionnaire user interaction satisfaction) self-reported in a secondary care hospital operating EMR(electronic medical record) system in Korea. Participants were two hundred fifty nurses in BSNUH. All of them were registered nurses participated in day-to-day nursing care during study periods. Participants were asked to fill in the SNCEQ(The Staggers Nursing Computer Experience Questionnaire) and QUIS(Questionnaire for User Interaction Satisfaction). Also requested were the data input time(sec) required for entry of approximately 20 times of nursing documentation tasks and the number of standardized precoordinated phrases used for documenting routine nursing records. The mean score of user satisfaction was 4.56 (SD 1.25) and the mean time of data input and the average number of precoordinated phrases used in nurses notes was 2.25min and 3.7 respectively.