Implementation of Structured Documentation and Standard Nursing Statements: Perceptions of Nurses in Acute Care Settings

Computers, Informatics, Nursing : CIN
Seonah LeeEun Ok Kim

Abstract

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, stak...Continue Reading

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Citations

May 31, 2020·Journal of Clinical Nursing·Elisabeth ØstensenRagnhild Hellesø

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