Developing an Electronic Nursing Record System for Clinical Care and Nursing Effectiveness Research in a Korean Home Healthcare Setting

Abstract

Increased accountability requirements for the cost and quality of healthcare force nurses to clearly define and verify nursing's contributions to patient outcomes. This demand necessitates documentation of nursing care in a precise manner. An electronic nursing record system is considered a key element that enhances nurses' ability not only to record nursing care provided to patients but also to measure, report, and monitor quality and effectiveness. Home care is a growing field as nurses attempt to meet the demand for long-term care. The development of an electronic record system for home care nursing was the immediate focus of this study. We identified the nursing content required for home care nursing using standardized nursing languages and designed linkages among medical diagnoses, nursing diagnoses, nursing interventions, and nursing-sensitive outcomes within the system. Equipping an electronic nursing record system with nursing standards is particularly critical for enhancing nursing practice and for creating refined data to verify nursing effectiveness.

Is it time for a comprehensive approach in older home care clients’ care planning in Finland?

“…The typical, standardised form of documentation includes goals, interventions and expected outcomes of the care and service process that are planned and agreed upon in collaboration with clients and professionals . It is found as an appropriate tool for documentation of care and service plans, because of its practical accessibility but also because of its impacts on quality of nursing and care planning .…”

“…Most studies have been performed in institutions such as hospitals or nursing homes . A few studies have concentrated on the comprehensiveness of care planning and nursing documentation in older clients’ home care.…”

Sistemas de classificação de enfermagem e sua aplicação na assistência: revisão integrativa de literatura

“…Um dos estudos, realizado na Coreia, descreveu o desenvolvimento de um sistema de registro eletrônico para enfermagem em cuidado domiciliar. Esse sistema facilitou o processo de tomada de decisões e a seleção de diagnósticos, intervenções e resultados de enfermagem (16) .…”

Can We Get Better Value for Money in Long-term Care?

“…In South Korea, the introduction of electronic equipment for home-care management was associated with better and more precise patient evaluations by nurses (Lee et al, 2009).…”

“…However, the introduction of ICT in community nursing in Slovenia lead nurses to spend more time on computers than with patients (Bitenc et al, 2000). Similarly, home-care nurses in a Korean study evaluated electronic records as being burdensome and confusing (Lee et al, 2009). ICT may be better suited for recipients with relatively mild disabilities.…”