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

LEE, EUN JOO PhD, RN; LEE, MIKYOUNG PhD, RN; MOORHEAD, SUE PhD, RN

CIN: Computers, Informatics, Nursing:
doi: 10.1097/NCN.0b013e3181a91b75
Feature Article
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.

Author Information

Author Affiliations: College of Nursing, Kyungpook National University, Daegu, South Korea (Dr Lee); and College of Nursing, The University of Iowa (Drs Lee and Moorhead).

This study was supported by a Korea Research Foundation grant (KRF-2006-521-E00129) from the Ministry of Education and Human Resource Development, South Korea.

Corresponding author: Mikyoung Lee, PhD, RN, College of Nursing, The University of Iowa, 50 Newton Rd, Iowa City, IA 52242 (mikyoung-lee@uiowa.edu).

© 2009 Lippincott Williams & Wilkins, Inc.