A Comparison of the Nursing Records of Hysterectomy Patients: Pre and Post Implementation of an ICNP Based Electronic Nursing Record System

Objective: This study compared the abilities of electronic nursing records, which are based on standard nursing terminology, and paper-based nursing records to support the nursing process. Methods: The nursing records of 38 pairs of inpatients admitted to a gynecology nursing unit were selected. The data from the paper records were obtained manually by a chart review as single statement units. The electronic records were extracted from a computerized system. The statements were categorized using the NANDA diagnosis and the modified Clinical Care Classification. Based on a semantic analysis of the components of the nursing process, the completeness of the nursing records was classified into complete and incomplete patterns according to the presence and relevancy of the assessment, the diagnosis, the intervention and the outcome. Results: The numbers of nursing diagnoses used and the unique nursing diagnoses were both higher in the electronic records than those in the paper records. The number of statements of nursing assessments/outcomes, and nursing interventions was 1.4-fold higher in the electronic records than that in the paper records respectively. The proportion of complete patterns of the nursing process was 3.4% in the paper records and 25.7% in the electronic records. Conclusion: These results suggest that electronic records are better than paper records to support the nursing process in terms of the quantitative and qualitative aspects of nursing documentation. (Journal of Korean Society of Medical Informatics 15-4, 455-464, 2009)