Reinterpreting the nursing record for an electronic context
| Autor: | Walter Sermeus, Patricia C. Dykes, Nicholas R. Hardiker, Dawn Dowding |
|---|---|
| Rok vydání: | 2019 |
| Předmět: |
Decision support system
020205 medical informatics Nursing Records Health Personnel Best practice Decision Making Health Informatics Context (language use) 02 engineering and technology Terminology 03 medical and health sciences 0302 clinical medicine nursing Nursing terminology 0202 electrical engineering electronic engineering information engineering Electronic Health Records Humans Narrative 030212 general & internal medicine Sociology requirements Data Collection electronic health record quality indicators Automatic summarization Work (electrical) user-computer interface Informatics decision support systems |
| Zdroj: | Hardiker, N R, Dowding, D, Dykes, P C & Sermeus, W 2019, ' Reinterpreting the nursing record for an electronic context ', International journal of medical informatics . https://doi.org/10.1016/j.ijmedinf.2019.04.021 |
| ISSN: | 1386-5056 |
| DOI: | 10.1016/j.ijmedinf.2019.04.021 |
| Popis: | BackgroundThis article seeks to facilitate the re-imagining of nursing records purposefully within an electronic context. It questions existing approaches to nursing documentation, critically examines existing nursing record systems and identifies new requirements.MethodsA comprehensive literature review was conducted to identify themes, that might meaningfully contribute to a new approach to nursing record systems development, around four key interrelated areas - standards, decision making, abstraction and summarization, and documenting. Studies were analyzed using narrative synthesis to provide a critical analysis of the current ‘state of the art’, and recommendations for the future.ResultsIncluded studies collectively described aspects of current best practice, both in terms of nursing record systems themselves, and how nurses and other health professionals contribute to and engage with those systems. A number of cross-cutting themes identified more novel approaches taken by nurses to systems development: going back to basics in determining purpose; firming up informatics foundations; nuancing or tailoring to suit different requirements; and engagement, involvement and participation.ConclusionThere is a paucity of research that specifically focuses on the nature of the electronic nursing record and its impact on patient care processes and outcomes. In addition to further research in these areas, there is a need: to reinterpret nurses as knowledge workers rather than as ‘data collectors’; to agree on the application in practice of appropriate standards and terminologies; and to work together with system developers to change the ways in which data are captured and care is documented. |
| Databáze: | OpenAIRE |
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