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Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System

OBJECTIVES: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. METHODS: This study was carried out in five phases: 1) generating nursing statemen...

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Autores principales: Park, Hyeoun-Ae, Min, Yul Ha, Jeon, Eunjoo, Chung, Eunja
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Korean Society of Medical Informatics 2012
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402556/
https://www.ncbi.nlm.nih.gov/pubmed/22844649
http://dx.doi.org/10.4258/hir.2012.18.2.136
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author Park, Hyeoun-Ae
Min, Yul Ha
Jeon, Eunjoo
Chung, Eunja
author_facet Park, Hyeoun-Ae
Min, Yul Ha
Jeon, Eunjoo
Chung, Eunja
author_sort Park, Hyeoun-Ae
collection PubMed
description OBJECTIVES: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. METHODS: This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. RESULTS: We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. CONCLUSIONS: The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.
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spelling pubmed-34025562012-07-27 Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System Park, Hyeoun-Ae Min, Yul Ha Jeon, Eunjoo Chung, Eunja Healthc Inform Res Original Article OBJECTIVES: The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. METHODS: This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. RESULTS: We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. CONCLUSIONS: The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system. Korean Society of Medical Informatics 2012-06 2012-06-30 /pmc/articles/PMC3402556/ /pubmed/22844649 http://dx.doi.org/10.4258/hir.2012.18.2.136 Text en © 2012 The Korean Society of Medical Informatics http://creativecommons.org/licenses/by-nc/3.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Original Article
Park, Hyeoun-Ae
Min, Yul Ha
Jeon, Eunjoo
Chung, Eunja
Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System
title Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System
title_full Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System
title_fullStr Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System
title_full_unstemmed Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System
title_short Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System
title_sort integration of evidence into a detailed clinical model-based electronic nursing record system
topic Original Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402556/
https://www.ncbi.nlm.nih.gov/pubmed/22844649
http://dx.doi.org/10.4258/hir.2012.18.2.136
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