J Korean Soc Med Inform.  2008 Jun;14(2):161-168.

Availability of nursing data in an electronic nursing record system for a development of a risk assessment tool for pressure ulcers

• Cho IS
• Yoon HY
• Park SI
• Lee HS

Abstract

OBJECTIVES
This study explored the reuse of data captured by nurses to support nursing decisions related to pressure-ulcer care.
METHODS
To examine the existence of coded data in an electronic nursing record system for the identified concepts, we used the electronic nursing documents of a teaching hospital in Gyeonggi-Do, in Korea. A surgical intensive care unit (SICU) was selected as the test unit due to the high incidence of pressure ulcers. The concepts were identified from literature review and refined through the involvement of staff nurses.
RESULTS
We found that 93.4% of the necessary concepts were matched semantically with data items at the input level of the electronic medical record system. Eighteen concepts (60%) were directly matched with the data variables of structured electronic nursing records. Five concepts (16.7%) were matched into more than two items. Including the standard nursing statements coded in Nurses' notes, five concepts were mapped more.
CONCLUSIONS
More than 90% of the concepts were matched successfully, which suggests that the secondary use of the routine data collected in an EMR system could be used to develop an automated risk assessment tool for pressure ulcers.

Keyword

Computerized Medical Records System; Electronic Nursing Records; Pressure Ulcer; Nursing Practice Data

MeSH Terms

Electronic Health Records
Electronics
Electrons
Hospitals, Teaching
Incidence
Critical Care
Korea
Medical Records Systems, Computerized
Nursing Records
Pressure Ulcer
Risk Assessment