FEATURESImplementation of an Electronic Nursing Record for Nursing Documentation and Communication of Patient Care Information in a Tertiary Teaching HospitalLee, Myeong-Seon MSN, RN; Lee, Seonah PhD, RNAuthor Information Author Affiliations: Department of Nursing, Nambu University (Ms Lee); and College of Nursing, Chonnam National University, Gwangju, Republic of Korea (Dr Lee). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Seonah Lee, PhD, RN, College of Nursing, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 61469, Republic of Korea ([email protected]). The study protocol was approved by the institutional review board of the Chonnam National University (approval no. 1040198-180912-HR-080-03). Author contributions: Seonah Lee developed the concept and design of the study; developed the questionnaire; conducted data analysis and interpretation; wrote and made critical revisions of the manuscript for important intellectual content; and gave the approval of the final version of the manuscript to be submitted. Myeong-Seon Lee helped the development and revision of the instruments; administered a pilot test of the questionnaire and a survey; critically reviewed the manuscript and provided revisions for important intellectual content; and gave the approval of the final version of the manuscript to be submitted. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.cinjournal.com). CIN: Computers, Informatics, Nursing: March 2021 - Volume 39 - Issue 3 - p 136-144 doi: 10.1097/CIN.0000000000000642 Buy SDC Metrics Abstract Despite the fact that implementing an electronic nursing record has become an everyday event for nurses, little is known about which type of documentation used in an electronic nursing record is better for nursing practice. The aim of this exploratory study was to identify the most suitable type of electronic nursing documentation that nurses used to record care and communicate with clinicians. Participants consisted of 118 nurses and 12 physicians. Researchers developed a self-report questionnaire of 17 items about electronic nursing record use for documentation and communication of patient care information. Data were analyzed using descriptive statistics to calculate frequencies and percentages. The χ2 test was used to identify differences in responses by demographic and clinical characteristics of participants. Bar charts were used to identify response patterns. Results showed that semistructured nursing documentation was the most preferred for care documentation and communication of patient information. Nurses did not always use the electronic nursing record to communicate patient care-related information. This study adds empirical knowledge about which type of documentation used in the electronic nursing record works well, what improvement is needed for better nursing practice, and whether the electronic nursing record has been used for communication. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.