edoc

Representing the nursing process with nursing terminologies in electronic medical record systems: a Swiss approach

Bernhart-Just, Alexandra and Lassen, Britta and Schwendimann, René. (2010) Representing the nursing process with nursing terminologies in electronic medical record systems: a Swiss approach. CIN: Computers, informatics, nursing, Vol. 28, H. 6. pp. 345-352.

Full text not available from this repository.

Official URL: http://edoc.unibas.ch/dok/A6005172

Downloads: Statistics Overview

Abstract

This article describes a framework model within a selected nursing classification system for the integration of nursing care processes into a clinical information system. The "Electronic Nursing Process Data Model," project was carried out from July 2004 to October 2006 in the Canton of Zurich in Switzerland. The Zurich Electronic Nursing Process Data Model integrates the nursing diagnosis, outcomes, and intervention terminologies in a standardized manner into the nursing care process within the electronic patient record. Findings of the pretest application in clinical nursing practices revealed that (1) functionalities are logically structured, (2) it is difficult to overview many details of the documentation, (3) a specific "to-do list" retrieved from the electronic system is needed, and (4) free-text entries are important to add description of the patient's situation. Furthermore, a consistent assessment terminology needs to be linked to the nursing diagnosis, outcomes, and intervention terminologies and the descriptions of nursing care process within the Electronic Nursing Process Data Model. As the project team, we recommend to implement the developed Electronic Nursing Process Data Model into professional software of clinical information systems and gradually into clinical practice. Therefore, an appropriate utilization strategy includes issues to improve nurses' understanding of the nursing care process and critical-thinking skills: not even the most comprehensive software program can substitute for facilitation.
Faculties and Departments:03 Faculty of Medicine > Departement Public Health > Institut für Pflegewissenschaft
UniBasel Contributors:Schwendimann, René
Item Type:Article, refereed
Article Subtype:Research Article
Bibsysno:Link to catalogue
Publisher:Lippincott Williams & Wilkins
ISSN:1538-2931
Note:Publication type according to Uni Basel Research Database: Journal article
Related URLs:
Identification Number:
Last Modified:24 May 2013 09:23
Deposited On:24 May 2013 09:21

Repository Staff Only: item control page