ObjectivesTo investigate the factors associated with the timeliness of electronic nursing documentation using the entry time on the Electronic Medical Record (EMR) system.MethodsAs a retrospective study, data were extracted from January 1 to February 28, 2014 from a hospital EMR system and a nurses’ personnel information system. The timeliness of instances of nursing documentation was categorized into ‘timely’ or ‘untimely’ according to whether the entry time was time-stamped within the working hours during each day, evening, or night shift. Factors associated with the timeliness of the electronic nursing documentation were included in the logistic regression models as nurse- and patient-associated factors.ResultsAmong 1,700,247 instances of electronic nursing documentation, 79.3% (n = 1,347,711) were completed within the working hours. Years of nursing experience, nursing shift, days of the week, patients’ age, and medical department had a statistically significant associated with the timeliness of nursing records. Nurses with experience of more than 1 year entered nursing records over 2 times more during their working hours than did less experienced nurses. During the evening and night shifts, nurses were 1.49 times and 9.19 times more likely to enter nursing documents in a timely manner, respectively, as compared to those in the day shift.ConclusionsNursing documentation was typically completed outside of working hours when a nurse had little experience, worked during the day shift or weekdays, and when tasks were unpredictable. This shows that new nurses need support to familiarize them with various tasks and the overall workflow.
Aims This study aimed to investigate the differences in practices, policies, and perceptions of nurses regarding work‐related utilization of smartphones in acute‐care settings. Background Mobile devices utilizing emerging technology are widely used in acute‐care settings; however, concerns such as potential distraction, improper use, and negative impact on the nursing image in clinical practice remain valid. Methods Nurse managers (n = 8) and nurses (n = 181) were enrolled from eight academic tertiary hospitals that have comprehensive electronic medical record systems and mobile versions. Between October 2018 and February 2019, participants completed a questionnaire designed to explore their use of smartphones. The reporting guide for self‐administered surveys of clinicians was applied. Results Approximately 80% of nurses carried personal smartphones while working, with 70% using their devices for work. The prevalence of work‐related smartphone use ranged from 3% to 43% by functionality, which was lower than that estimated by managers. Frequent uses included taking pictures/videos and internet browsing. Nurses were more positive than managers about the benefits of smartphone use and less burdened by related concerns. Novice and junior nurses were more optimistic than senior nurses. Only one hospital had a policy on nurses’ use of personal devices at work. Conclusion Two unmet needs in the current clinical information system were identified: information supporting task‐related knowledge at the bedside and security of data capture and communication. Implication for nursing policy The unintended perception gaps between nurses and managers regarding work‐related smartphone use can be closed by nursing leadership. Unmet nursing informatics, particularly for information‐seeking purposes, can be addressed in the context of quality assurance. Nurse leaders can advocate secure and proper use of smartphones in clinical practice.
ObjectivesThis paper describes the integrated Careplan system, designed to manage and utilize the existing Electronic Medical Record (EMR) system; the system also defines key items for interdisciplinary communication and continuity of patient care.MethodsWe structured the Careplan system to provide effective interdisciplinary communication for healthcare services. The design of the Careplan system architecture proceeded in four steps-defining target datasets; construction of conceptual framework and architecture; screen layout and storyboard creation; screen user interface (UI) design and development, and pilot test and step-by-step deployment. This Careplan system architecture consists of two parts, a server-side and client-side area. On the server-side, it performs the roles of data retrieval and storage from target EMRs. Furthermore, it performs the role of sending push notifications to the client depending on the careplan series. Also, the Careplan system provides various convenient modules to easily enter an individual careplan.ResultsCurrently, Severance Hospital operates the Careplan system and provides a stable service dealing with dynamic changes (e.g., domestic medical certification, the Joint Commission International guideline) of EMR.ConclusionsThe Careplan system should go hand in hand with key items for strengthening interdisciplinary communication and information sharing within the EMR environment. A well-designed Careplan system can enhance user satisfaction and completed performance.
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