메뉴 건너뛰기




Volumn 79, Issue 8, 2010, Pages 554-564

Evaluation of electronic nursing documentation-Nursing process model and standardized terminologies as keys to visible and transparent nursing

Author keywords

Classification; Computerized; Evaluation; Medical records; Nursing documentation; Terminology

Indexed keywords

CENTRAL HOSPITALS; COMPUTERIZED EVALUATION; CONTENT ANALYSIS; ELECTRONIC HEALTH RECORD; EVALUATION; HEALTH CARE PROFESSIONALS; MEDICAL RECORD; NEEDS ASSESSMENT; NEUROLOGICAL PATIENT; NURSING CARE; NURSING DOCUMENTATION; NURSING INTERVENTIONS; NURSING PROCESS; PATIENT CARE; PATIENT SAFETY; SURGICAL PATIENTS;

EID: 77954349425     PISSN: 13865056     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.ijmedinf.2010.05.002     Document Type: Article
Times cited : (56)

References (51)
  • 1
    • 77954349200 scopus 로고    scopus 로고
    • ISO/TR 20514, Health Informatics - Electronic Health Record - Definition, Scope, and Context 2005. Available from: 22.01.2010.
    • ISO/TR 20514, Health Informatics - Electronic Health Record - Definition, Scope, and Context 2005. Available from: 22.01.2010. http://www.openehr.org/downloads/standards/iso/isotc215wg3_N202_ISO-TR_2 0514_Final_%5B2005-01-31%5D.pdf.
  • 2
    • 70249086915 scopus 로고    scopus 로고
    • Nursing record systems: effects on nursing practice and healthcare outcomes
    • Art. No.: CD002099.pub2
    • Urquhart C., Currell R., Grant M.J., Hardiker N.R. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Database Syst. Rev. 2009, (1). Art. No.: CD002099.pub2. 10.1002/14651858.
    • (2009) Cochrane Database Syst. Rev. , Issue.1
    • Urquhart, C.1    Currell, R.2    Grant, M.J.3    Hardiker, N.R.4
  • 4
    • 34250806595 scopus 로고    scopus 로고
    • Effects of a computer-based nursing documentation system on the quality of nursing documentation
    • Mahler C., Ammenwerth E., Wagner A., Tautz A., Happek T., Hoppe B., Eichstadter R. Effects of a computer-based nursing documentation system on the quality of nursing documentation. J. Med. Syst. 2007, 31(August (4)):274-282.
    • (2007) J. Med. Syst. , vol.31 August , Issue.4 , pp. 274-282
    • Mahler, C.1    Ammenwerth, E.2    Wagner, A.3    Tautz, A.4    Happek, T.5    Hoppe, B.6    Eichstadter, R.7
  • 5
    • 41149088350 scopus 로고    scopus 로고
    • Definition, structure, content, use and impacts of electronic health records: a review of the research literature
    • Häyrinen K., Saranto K., Nykänen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int. J. Med. Inform. 2008, 77(May (5)):291-304.
    • (2008) Int. J. Med. Inform. , vol.77 May , Issue.5 , pp. 291-304
    • Häyrinen, K.1    Saranto, K.2    Nykänen, P.3
  • 6
    • 59449103937 scopus 로고    scopus 로고
    • Evaluating nursing documentation-research designs and methods: systematic review
    • Saranto K., Kinnunen U.M. Evaluating nursing documentation-research designs and methods: systematic review. J. Adv. Nurs. 2009, 65(March (3)):464-476.
    • (2009) J. Adv. Nurs. , vol.65 March , Issue.3 , pp. 464-476
    • Saranto, K.1    Kinnunen, U.M.2
  • 8
    • 0024445436 scopus 로고
    • Computerized nurse charting
    • Pryor T.A. Computerized nurse charting. Int. J. Clin. Monit. Comput. 1989, 6(July (3)):173-179.
    • (1989) Int. J. Clin. Monit. Comput. , vol.6 July , Issue.3 , pp. 173-179
    • Pryor, T.A.1
  • 9
    • 0026472330 scopus 로고
    • Computer-supported versus manually-generated nursing care plans: a comparison of patient problems, nursing interventions, and AIDS patient outcomes
    • Holzemer W.L., Henry S.B. Computer-supported versus manually-generated nursing care plans: a comparison of patient problems, nursing interventions, and AIDS patient outcomes. Comput. Nurs. 1992, 10(January-February (1)):19-24.
    • (1992) Comput. Nurs. , vol.10 January-February , Issue.1 , pp. 19-24
    • Holzemer, W.L.1    Henry, S.B.2
  • 10
    • 0035289577 scopus 로고    scopus 로고
    • Evaluation of documentation before and after implementation of a nursing information system in an acute care hospital
    • quiz 66-8
    • Larrabee J.H., Boldreghini S., Elder-Sorrells K., Turner Z.M., Wender R.G., Hart J.M., Lenzi P.S. Evaluation of documentation before and after implementation of a nursing information system in an acute care hospital. Comput. Nurs. 2001, 19(March-April (2)):56-65. quiz 66-8.
    • (2001) Comput. Nurs. , vol.19 March-April , Issue.2 , pp. 56-65
    • Larrabee, J.H.1    Boldreghini, S.2    Elder-Sorrells, K.3    Turner, Z.M.4    Wender, R.G.5    Hart, J.M.6    Lenzi, P.S.7
  • 11
    • 0036726832 scopus 로고    scopus 로고
    • Written and computerized care plans, organizational processes and effect on patient outcomes
    • Daly J.M., Buckwalter K., Maas M. Written and computerized care plans, organizational processes and effect on patient outcomes. J. Gerontol. Nurs. 2002, 28(September (9)):14-23.
    • (2002) J. Gerontol. Nurs. , vol.28 September , Issue.9 , pp. 14-23
    • Daly, J.M.1    Buckwalter, K.2    Maas, M.3
  • 12
    • 0036122693 scopus 로고    scopus 로고
    • Long-term increase in quality of nursing documentation: effects of a comprehensive intervention
    • Björvell C., Wredling R., Thorell-Ekstrand I. Long-term increase in quality of nursing documentation: effects of a comprehensive intervention. Scand. J. Caring Sci. 2002, 16(March (1)):34-42.
    • (2002) Scand. J. Caring Sci. , vol.16 March , Issue.1 , pp. 34-42
    • Björvell, C.1    Wredling, R.2    Thorell-Ekstrand, I.3
  • 13
    • 0242271911 scopus 로고    scopus 로고
    • Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district
    • Ehrenberg A., Birgersson C. Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district. Scand. J. Caring Sci. 2003, 17(September (3)):278-284.
    • (2003) Scand. J. Caring Sci. , vol.17 September , Issue.3 , pp. 278-284
    • Ehrenberg, A.1    Birgersson, C.2
  • 14
    • 0037604709 scopus 로고    scopus 로고
    • Applicability of the international classification of nursing practice (ICNP) in the areas of nutrition and skin care
    • Ehnfors M., Florin J., Ehrenberg A. Applicability of the international classification of nursing practice (ICNP) in the areas of nutrition and skin care. Int. J. Nurs. Terminol. Classif. 2003, 14(January-March (1)):5-18.
    • (2003) Int. J. Nurs. Terminol. Classif. , vol.14 January-March , Issue.1 , pp. 5-18
    • Ehnfors, M.1    Florin, J.2    Ehrenberg, A.3
  • 15
    • 16544391899 scopus 로고    scopus 로고
    • Electronic nursing documentation in primary health care
    • Törnvall E., Wilhelmsson S., Wahren L.K. Electronic nursing documentation in primary health care. Scand. J. Caring Sci. 2004, 18(September (3)):310-317.
    • (2004) Scand. J. Caring Sci. , vol.18 September , Issue.3 , pp. 310-317
    • Törnvall, E.1    Wilhelmsson, S.2    Wahren, L.K.3
  • 16
    • 34547740133 scopus 로고    scopus 로고
    • Impact of primary care management on nursing documentation
    • Törnvall E., Wahren L.K., Wilhelmsson S. Impact of primary care management on nursing documentation. J. Nurs. Manag. 2007, 15(September (6)):634-642.
    • (2007) J. Nurs. Manag. , vol.15 September , Issue.6 , pp. 634-642
    • Törnvall, E.1    Wahren, L.K.2    Wilhelmsson, S.3
  • 18
    • 0031136436 scopus 로고    scopus 로고
    • Nursing classification systems: necessary but not sufficient for representing " What Nurses Do" for inclusion in computer-based patient record systems
    • Henry S.B., Mead C.N. Nursing classification systems: necessary but not sufficient for representing " What Nurses Do" for inclusion in computer-based patient record systems. J. Am. Med. Inform. Assoc. 1997, 4(May-June (3)):222-232.
    • (1997) J. Am. Med. Inform. Assoc. , vol.4 May-June , Issue.3 , pp. 222-232
    • Henry, S.B.1    Mead, C.N.2
  • 19
    • 0031870164 scopus 로고    scopus 로고
    • A review of major nursing vocabularies and the extent to which they have the characteristics required for implementation in computer-based systems
    • Henry S.B., Warren J.J., Lange L., Button P. A review of major nursing vocabularies and the extent to which they have the characteristics required for implementation in computer-based systems. J. Am. Med. Inform. Assoc. 1998, 5(July-August (4)):321-328.
    • (1998) J. Am. Med. Inform. Assoc. , vol.5 July-August , Issue.4 , pp. 321-328
    • Henry, S.B.1    Warren, J.J.2    Lange, L.3    Button, P.4
  • 20
    • 0033769776 scopus 로고    scopus 로고
    • Standards for nursing terminology
    • Hardiker N.R., Hoy D., Casey A. Standards for nursing terminology. J. Am. Med. Inform. Assoc. 2000, 7(November-December (6)):523-528.
    • (2000) J. Am. Med. Inform. Assoc. , vol.7 November-December , Issue.6 , pp. 523-528
    • Hardiker, N.R.1    Hoy, D.2    Casey, A.3
  • 22
    • 0034572974 scopus 로고    scopus 로고
    • Describing patient problems & nursing treatment patterns using nursing minimum data sets (NMDS & NMMDS) & UHDDS repositories
    • Delaney C., Reed D., Clarke M. Describing patient problems & nursing treatment patterns using nursing minimum data sets (NMDS & NMMDS) & UHDDS repositories. Proc. AMIA Symp. 2000, 176-179.
    • (2000) Proc. AMIA Symp. , pp. 176-179
    • Delaney, C.1    Reed, D.2    Clarke, M.3
  • 23
    • 4143075872 scopus 로고    scopus 로고
    • Using a nursing minimum data set with older patients with dementia in an acute care setting
    • Park M., Delaney C., Maas M., Reed D. Using a nursing minimum data set with older patients with dementia in an acute care setting. J. Adv. Nurs. 2004, 47(August (3)):329-339.
    • (2004) J. Adv. Nurs. , vol.47 August , Issue.3 , pp. 329-339
    • Park, M.1    Delaney, C.2    Maas, M.3    Reed, D.4
  • 24
    • 20444396192 scopus 로고    scopus 로고
    • Evaluating the impact of computerized clinical documentation
    • Smith K., Smith V., Krugman M., Oman K. Evaluating the impact of computerized clinical documentation. Comput. Inform. Nurs. 2005, 23(May-June (3)):132-138.
    • (2005) Comput. Inform. Nurs. , vol.23 May-June , Issue.3 , pp. 132-138
    • Smith, K.1    Smith, V.2    Krugman, M.3    Oman, K.4
  • 25
    • 0031261624 scopus 로고    scopus 로고
    • Criteria for nursing information systems as a component of the electronic patient record. An international Delphi study
    • Goossen W.T., Epping P.J., Dassen T. Criteria for nursing information systems as a component of the electronic patient record. An international Delphi study. Comput. Nurs. 1997, 15(November-December (6)):307-315.
    • (1997) Comput. Nurs. , vol.15 November-December , Issue.6 , pp. 307-315
    • Goossen, W.T.1    Epping, P.J.2    Dassen, T.3
  • 26
    • 0034282540 scopus 로고    scopus 로고
    • Research needs and priorities in health informatics
    • Brender J., Nohr C., McNair P. Research needs and priorities in health informatics. Int. J. Med. Inform. 2000, 58-59(September):257-289.
    • (2000) Int. J. Med. Inform. , vol.58-59 September , pp. 257-289
    • Brender, J.1    Nohr, C.2    McNair, P.3
  • 27
    • 0035177398 scopus 로고    scopus 로고
    • Delivering the electronic healthcare record for the 21st century
    • Grimson J. Delivering the electronic healthcare record for the 21st century. Int. J. Med. Inform. 2001, 64(December (2-3)):111-127.
    • (2001) Int. J. Med. Inform. , vol.64 December , Issue.2-3 , pp. 111-127
    • Grimson, J.1
  • 28
    • 0036016997 scopus 로고    scopus 로고
    • The computerized patient record: balancing effort and benefit
    • van Ginneken A.M. The computerized patient record: balancing effort and benefit. Int. J. Med. Inform. 2002, 65(June (2)):97-119.
    • (2002) Int. J. Med. Inform. , vol.65 June , Issue.2 , pp. 97-119
    • van Ginneken, A.M.1
  • 29
    • 0034218672 scopus 로고    scopus 로고
    • Frequency of and indications for wholly compensatory nursing care related to enteral food intake: a secondary analysis of the Belgium National Nursing Minimum Data Set
    • Evers G., Viane A., Sermeus W., Simoens-De Smet A., Delesie L. Frequency of and indications for wholly compensatory nursing care related to enteral food intake: a secondary analysis of the Belgium National Nursing Minimum Data Set. J. Adv. Nurs. 2000, 32(July (1)):194-201.
    • (2000) J. Adv. Nurs. , vol.32 July , Issue.1 , pp. 194-201
    • Evers, G.1    Viane, A.2    Sermeus, W.3    Simoens-De Smet, A.4    Delesie, L.5
  • 30
    • 0034567006 scopus 로고    scopus 로고
    • The evolution of a clinical database: from local to standardized clinical languages
    • Prophet C.M. The evolution of a clinical database: from local to standardized clinical languages. Proc. AMIA Symp. 2000, 660-664.
    • (2000) Proc. AMIA Symp. , pp. 660-664
    • Prophet, C.M.1
  • 31
    • 0035379998 scopus 로고    scopus 로고
    • Using the nursing minimum data set for the Netherlands (NMDSN) to illustrate differences in patient populations and variations in nursing activities
    • Goossen W.T., Epping P.J., Feuth T., van den Heuvel W.J., Hasman A., Dassen T.W. Using the nursing minimum data set for the Netherlands (NMDSN) to illustrate differences in patient populations and variations in nursing activities. Int. J. Nurs. Stud. 2001, 38(June (3)):243-257.
    • (2001) Int. J. Nurs. Stud. , vol.38 June , Issue.3 , pp. 243-257
    • Goossen, W.T.1    Epping, P.J.2    Feuth, T.3    van den Heuvel, W.J.4    Hasman, A.5    Dassen, T.W.6
  • 32
    • 0035489542 scopus 로고    scopus 로고
    • Exploring the nursing minimum data set for the Netherlands using multidimensional scaling techniques
    • Griens A.M., Goossen W.T., Van der Kloot W.A. Exploring the nursing minimum data set for the Netherlands using multidimensional scaling techniques. J. Adv. Nurs. 2001, 36(October (1)):89-101.
    • (2001) J. Adv. Nurs. , vol.36 October , Issue.1 , pp. 89-101
    • Griens, A.M.1    Goossen, W.T.2    Van der Kloot, W.A.3
  • 33
    • 0037132491 scopus 로고    scopus 로고
    • Statistical analysis of the nursing minimum data set for the Netherlands
    • Goossen W.T. Statistical analysis of the nursing minimum data set for the Netherlands. Int. J. Med. Inform. 2002, 68(December (1-3)):205-218.
    • (2002) Int. J. Med. Inform. , vol.68 December , Issue.1-3 , pp. 205-218
    • Goossen, W.T.1
  • 34
    • 39049194459 scopus 로고    scopus 로고
    • Nationally standardized electronic nursing documentation in Finland by the year 2007
    • Tanttu K., Ikonen H. Nationally standardized electronic nursing documentation in Finland by the year 2007. Stud. Health Technol. Inform. 2006, 122:540-541.
    • (2006) Stud. Health Technol. Inform. , vol.122 , pp. 540-541
    • Tanttu, K.1    Ikonen, H.2
  • 35
    • 0036361849 scopus 로고    scopus 로고
    • Nursing classifications: home health care classification system (HHCC): an overview
    • Saba V.K. Nursing classifications: home health care classification system (HHCC): an overview. Online J. Issues Nurs. 2002, 7(3):9.
    • (2002) Online J. Issues Nurs. , vol.7 , Issue.3 , pp. 9
    • Saba, V.K.1
  • 36
    • 0028538315 scopus 로고
    • Toward standard classification schemes for nursing language: recommendations of the American Nurses' Association Steering Committee on databases to support clinical nursing practice
    • McCormick K.A., Lang N., Zielstorff R., Milholland D.K., Saba V., Jacox A. Toward standard classification schemes for nursing language: recommendations of the American Nurses' Association Steering Committee on databases to support clinical nursing practice. J. Am. Med. Inform. Assoc. 1994, 1(November-December (6)):421-427.
    • (1994) J. Am. Med. Inform. Assoc. , vol.1 November-December , Issue.6 , pp. 421-427
    • McCormick, K.A.1    Lang, N.2    Zielstorff, R.3    Milholland, D.K.4    Saba, V.5    Jacox, A.6
  • 37
    • 0034133728 scopus 로고    scopus 로고
    • Validation of a new method for patient classification, the Oulu patient classification
    • Fagerström L., Rainio A.K., Rauhala A., Nojonen K. Validation of a new method for patient classification, the Oulu patient classification. J. Adv. Nurs. 2000, 31:481-490.
    • (2000) J. Adv. Nurs. , vol.31 , pp. 481-490
    • Fagerström, L.1    Rainio, A.K.2    Rauhala, A.3    Nojonen, K.4
  • 38
    • 77954349514 scopus 로고    scopus 로고
    • From free text to standardized nursing language-the national development project of nursing documentation in Finland, IT @ NETWORKING COMMUNICATIONS, ISSN 1784-0716/December 2009-April 2010. 11.4.2010.
    • K. Tanttu, From free text to standardized nursing language-the national development project of nursing documentation in Finland, IT @ NETWORKING COMMUNICATIONS, Volume 3/Issue 1, ISSN 1784-0716/December 2009-April 2010. 11.4.2010. http://hitm.eu/downloads/IT@09_Review.pdf.
    • , vol.3 , Issue.1
    • Tanttu, K.1
  • 40
    • 0025903680 scopus 로고
    • The nursing minimum data set: abstraction tool for standardized, comparable, essential data
    • Werley H.H., Devine E.C., Zorn C.R., Ryan P., Westra B.L. The nursing minimum data set: abstraction tool for standardized, comparable, essential data. Am. J. Public Health 1991, 81(April (4)):421-426.
    • (1991) Am. J. Public Health , vol.81 April , Issue.4 , pp. 421-426
    • Werley, H.H.1    Devine, E.C.2    Zorn, C.R.3    Ryan, P.4    Westra, B.L.5
  • 42
    • 77954349777 scopus 로고    scopus 로고
    • Structured Documentation in Nursing Discharge Summaries [Master's thesis on the Internet], University of Kuopio, 2006. Available from: 22.01.2010.
    • K. Remes, Structured Documentation in Nursing Discharge Summaries [Master's thesis on the Internet], University of Kuopio, 2006. Available from: 22.01.2010. http://www.uku.fi/tht/opinnaytteet/kmremesgradu.pdf.
    • Remes, K.1
  • 44
    • 77954349039 scopus 로고    scopus 로고
    • Structured Data in the Wound Care Documentation, Master's Thesis, University of Kuopio, 2007. Available from: 22.01.2010.
    • U.M. Kinnunen, Structured Data in the Wound Care Documentation, Master's Thesis, University of Kuopio, 2007. Available from: 22.01.2010. http://www.uku.fi/tht/opinnaytteet/UMKinnunengradu.pdf.
    • Kinnunen, U.M.1
  • 45
    • 16244365832 scopus 로고    scopus 로고
    • An inventory of evaluation studies of information technology in health care. Trends in evaluation research 1982-2002
    • Ammenwerth E., de Keizer N. An inventory of evaluation studies of information technology in health care. Trends in evaluation research 1982-2002. Methods Inf. Med. 2005, 44(1):44-56.
    • (2005) Methods Inf. Med. , vol.44 , Issue.1 , pp. 44-56
    • Ammenwerth, E.1    de Keizer, N.2
  • 46
    • 33750586060 scopus 로고    scopus 로고
    • Nursing diagnoses, interventions and outcomes-application and impact on nursing practice: systematic review
    • Müller-Staub M., Lavin M.A., Needham I., van Achterberg T. Nursing diagnoses, interventions and outcomes-application and impact on nursing practice: systematic review. J. Adv. Nurs. 2006, 56(December (5)):514-531.
    • (2006) J. Adv. Nurs. , vol.56 December , Issue.5 , pp. 514-531
    • Müller-Staub, M.1    Lavin, M.A.2    Needham, I.3    van Achterberg, T.4
  • 47
    • 0027719749 scopus 로고
    • Nursing care as documented in patient records
    • Ehnfors M., Smedby B. Nursing care as documented in patient records. Scand. J. Caring Sci. 1993, 7(4):209-220.
    • (1993) Scand. J. Caring Sci. , vol.7 , Issue.4 , pp. 209-220
    • Ehnfors, M.1    Smedby, B.2
  • 48
    • 0034096010 scopus 로고    scopus 로고
    • Development of an audit instrument for nursing care plans in the patient record
    • Björvell C., Thorell-Ekstrand I., Wredling R. Development of an audit instrument for nursing care plans in the patient record. Qual. Health Care. 2000, 9(March (1)):6-13.
    • (2000) Qual. Health Care. , vol.9 March , Issue.1 , pp. 6-13
    • Björvell, C.1    Thorell-Ekstrand, I.2    Wredling, R.3
  • 49
    • 0034264979 scopus 로고    scopus 로고
    • Measurement of the effects of an integrated, point-of-care computer system on quality of nursing documentation and patient satisfaction
    • Nahm R., Poston I. Measurement of the effects of an integrated, point-of-care computer system on quality of nursing documentation and patient satisfaction. Comput. Nurs. 2000, 18(September-October (5)):220-229.
    • (2000) Comput. Nurs. , vol.18 September-October , Issue.5 , pp. 220-229
    • Nahm, R.1    Poston, I.2
  • 50
    • 33645093464 scopus 로고    scopus 로고
    • Information handling in the nursing discharge note
    • Hellesø R. Information handling in the nursing discharge note. J. Clin. Nurs. 2006, 15(January (1)):11-21.
    • (2006) J. Clin. Nurs. , vol.15 January , Issue.1 , pp. 11-21
    • Hellesø, R.1
  • 51
    • 44449139161 scopus 로고    scopus 로고
    • Testing the Q-DIO as an instrument to measure the documented quality of nursing diagnoses. Interventions, and outcomes
    • Müller-Staub M., Lunney M., Lavin M.A., Needham I., Odenbreit M., van Achterberg T. Testing the Q-DIO as an instrument to measure the documented quality of nursing diagnoses. Interventions, and outcomes. Int. J. Nurs. Terminol. Classif. 2008, 19(January-March (1)):20-27.
    • (2008) Int. J. Nurs. Terminol. Classif. , vol.19 January-March , Issue.1 , pp. 20-27
    • Müller-Staub, M.1    Lunney, M.2    Lavin, M.A.3    Needham, I.4    Odenbreit, M.5    van Achterberg, T.6


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.