Implementation of a Next-Generation Electronic Nursing Records System Based on Detailed Clinical Models and Integration of Clinical Practice Guidelines

OBJECTIVES: The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system. METHODS: A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system. RESULTS: The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines. CONCLUSIONS: An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.