Shafiee Mohsen, Shanbehzadeh Mostafa, Nassari Zeinab, Kazemi-Arpanahi Hadi
Department of Nursing, Abadan University of Medical Sciences, Abadan, Iran.
Department of Health Information Technology, School of Paramedical, Ilam University of Medical Sciences, Ilam, Iran.
BMC Nurs. 2022 Jan 10;21(1):15. doi: 10.1186/s12912-021-00790-1.
Nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context.
A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of the MDS. Then, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Afterward, the ECNDS was developed according to the finalized MDS, and eventually, its performance was evaluated by involving the end-users.
The proposed MDS was divided into administrative and clinical sections; including nursing assessment and the nursing diagnosis process. Then, a web-based system with modular and layered architecture was developed based on the derived MDS. Finally, to evaluate the developed system, a survey of 150 registered nurses (RNs) was conducted to identify the positive and negative impacts of the system.
The developed system is suitable for the documentation of patient care in nursing care plans within a legal, ethical, and professional framework. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.
护理记录是护理工作流程的关键环节。科学文献和护理实践中对护理报告详细程度的描述各不相同，且未提供统一的结构化记录方式。本研究旨在描述电子临床护理记录系统（ECNDS）内容的设计与评估过程，以便在此背景下提供一致且统一的报告。
采用了四步顺序法。最小数据集（MDS）的开发过程包括两个阶段，具体如下：首先，进行文献综述以全面了解护理的相关要素，并梳理支撑MDS开发的现有证据。然后，使用两轮德尔菲研究对文献综述中纳入的数据进行分析，并由专家小组进行内容验证。之后，根据最终确定的MDS开发ECNDS，最后由终端用户参与评估其性能。
提议的MDS分为管理和临床部分；包括护理评估和护理诊断过程。然后，基于导出的MDS开发了一个具有模块化和分层架构的网络系统。最后，为评估开发的系统，对150名注册护士进行了调查，以确定该系统的积极和消极影响。
开发的系统适用于在法律、伦理和专业框架内记录护理计划中的患者护理情况。然而，护士需要在根据护理流程记录患者护理情况以及使用标准报告模板方面接受进一步培训，以提高患者安全性并改善记录工作。
