J Korean Soc Med Inform.  2009 Mar;15(1):83-91.

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

Affiliations
  • 1Seoul National University Hospital, Korea.
  • 2College of Nursing, Seoul National University, Korea. hapark@snu.ac.kr

Abstract


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.

Keyword

Nursing Record; Electronic Nursing Record; Nursing Process
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