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Evaluation of Electronic Health Records on the Nursing Process and Patient Outcomes Regarding Fall and Pressure Injuries

Wu, Mei-Wen MS, RN; Lee, Ting-Ting PhD, RN; Lai, Shu-Mei MS, RN; Huang, Chi-Yi PhD; Chang, Tsai-Hsiu PhD, RN

CIN: Computers, Informatics, Nursing: November 2019 - Volume 37 - Issue 11 - p 573–582
doi: 10.1097/CIN.0000000000000548
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Digitalizing the nursing process has become a trend in medical care. The purpose of this study was to evaluate implementation of the Standardized Computerized Nursing Process Documentation System and patient outcomes. We analyzed hospitalized patients' electronic health record database with a total of 19 659 patients in 2015. The analysis focused on nurses' selection of nursing care plans for patients with a high risk of falls or pressure injuries through admission assessments. The effectiveness of implemented nursing care plans following falls or pressure injuries was explored. The results reveal that 55% of the hospitalized patients had a risk of falling, and 27.85% of patients were at risk of pressure injuries. Patients receiving nursing care plan who experienced falls or pressure injuries were significantly higher than those without a nursing care plan (P < .001). This study could not provide direct evidence for the effect of nursing care plans on reducing the incidence of falls and pressure injuries, which may be attributable to patient characteristics. Furthermore, an analysis on data from 2007 to 2017 using a run chart revealed that the mean incidence rate for pressure injuries decreased, whereas that for falls remained stable. The results indicate that the system did not increase the occurrence of such incidences.

Author Affiliations: ChangHua Christian Hospital (Mss Lai and Wu and Dr Huang) and HungKuang University (Ms Wu, Dr Huang); School of Nursing, National Yang-Ming University (Dr Lee); and Department of Nursing, HungKuang University (Dr Chang), Taiwan, Republic of China.

This study was supported by a grant (105-CCH-IRP-151) to M.-W.W. from ChangHua Christian Hospital, Taiwan.

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

Corresponding author: Tsai-Hsiu Chang, PhD, RN, Department of Nursing, HungKuang University, No. 1018, Sec. 6, Taiwan Boulevard, Shalu District, Taichung City 43302, Taiwan (R.O.C.) (tchang24yttmy@gmail.com).

Online date: August 23, 2019

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