Developing an electronic nursing record system for clinical care and nursing effectiveness research in a Korean home healthcare setting

Eun Joo Lee, Mikyoung Lee, Sue Moorhead

Research output: Contribution to journalArticle

6 Scopus citations

Abstract

Increased accountability requirements for the cost and quality of healthcare force nurses to clearly define and verify nursing's contributions to patient outcomes. This demand necessitates documentation of nursing care in a precise manner. An electronic nursing record system is considered a key element that enhances nurses' ability not only to record nursing care provided to patients but also to measure, report, and monitor quality and effectiveness. Home care is a growing field as nurses attempt to meet the demand for long-term care. The development of an electronic record system for home care nursing was the immediate focus of this study. We identified the nursing content required for home care nursing using standardized nursing languages and designed linkages among medical diagnoses, nursing diagnoses, nursing interventions, and nursing-sensitive outcomes within the system. Equipping an electronic nursing record system with nursing standards is particularly critical for enhancing nursing practice and for creating refined data to verify nursing effectiveness.

Original languageEnglish (US)
Pages (from-to)234-244
Number of pages11
JournalCIN - Computers Informatics Nursing
Volume27
Issue number4
DOIs
StatePublished - Jul 1 2009

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Keywords

  • Effectiveness research
  • Electronic nursing record system
  • Home care nursing
  • NANDA
  • NIC
  • NOC

ASJC Scopus subject areas

  • Health Informatics
  • Nursing (miscellaneous)

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