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Implementation of Structured Documentation and Standard Nursing Statements

Perceptions of Nurses in Acute Care Settings

Lee, Seonah, PhD, RN; Jeon, Mi Yang, PhD, RN; Kim, Eun Ok, MSN, RN

CIN: Computers, Informatics, Nursing: May 2019 - Volume 37 - Issue 5 - p 266–275
doi: 10.1097/CIN.0000000000000510
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Nurses implement structured documentation using standardized nursing terminologies in computerized healthcare settings. Nurses' perceptions, shaped by their experiences of implementing such documentation, are an important indicator for the documentation system's optimal maintenance and improvement. The purpose of this study was to describe perceptions of nurses using SYSTEM featuring standard nursing statements and structured documentation. A quantitative cross-sectional study design was used. A total of 42 nurses from a tertiary teaching hospital participated in this study. A researcher-developed survey questionnaire included seven questions asking nurses' perceptions of nursing process phases and SYSTEM's usefulness, effectiveness, necessity, assistance in decision making, and suggestions for SYSTEM improvement. As results, the assessment phase was perceived to be the most necessary, while the planning phase was perceived to be the most unnecessary. Perceived disadvantages were decreased patient care time, increased charting time, and standard nursing statements not covering diverse patients' conditions. These disadvantages conflicted with perceived advantages. For successful implementation of electronic nursing records, stakeholders at clinical, information technology, and administrative levels should cooperate closely to address adverse consequences from implementation of structured documentation and standardized nursing terminologies.

Author Affiliations: College of Nursing, Chonnam National University, Gwangju (Dr Lee); and College of Nursing, Institute of Health Science, Gyeongsang National University (Dr Jeon); and Education Department of Nursing, Gyeongsang National University Hospital (Ms Kim), Jinju, Republic of Korea.

The study was approved by the Institutional Review Board of Gyeongsang National University (no. GIRB-A16-Y-0033).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Seonah Lee, PhD, RN, College of Nursing, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 61469, Republic of Korea (i.seonahlee@gmail.com).

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