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Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records
Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.ORCID iD: 0000-0002-3964-196X
2011 (English)In: Computers, Informatics, Nursing, ISSN 1538-2931, E-ISSN 1538-9774, Vol. 29, no 10, 599-607 p.Article in journal (Refereed) Published
Abstract [en]

The nursing process and standardized nursing terminologies are essential elements to structure nursing documentation in daily nursing information management. The aim of this study was to describe sustainability and whether and how standardized nursing terminologies, in handwritten versus preprinted versus computerized nursing care plans, changed the content and completeness of documented nursing care. Three audits of patient records were performed: a pretest (n = 291) before a yearlong implementation of standardized nursing terminologies in nursing care plans followed by two posttests: (1) 3 weeks after implementation of nursing terminologies (n = 299) and (2) 22 months after implementation of nursing terminologies and 8 months after implementation of a computerized system (n = 281) in a university hospital. Content and completeness of documented nursing care improved after implementation of standardized nursing terminologies. Documentation of nursing care plans, signs and symptoms, related factors, and nursing interventions increased, whereas mean number of nursing diagnoses per patient did not change between audits. Computerized nursing care plans had the biggest impact, with more variety of nursing diagnoses and increased documentation of signs and symptoms, related factors, and nursing interventions. The use of standardized nursing terminologies improved nursing content in the nursing care plans. Moreover, computerized nursing care plans, in comparison with handwritten and preprinted care plans, increased documentation completeness.

Place, publisher, year, edition, pages
Lippincott: Williams & Wilkins, Inc , 2011. Vol. 29, no 10, 599-607 p.
Keyword [en]
Care planning system; Computerized records; Nursing diagnosis; Nursing intervention; Record audit; Standardized nursing terminology
National Category
Health Sciences
Research subject
Hälsa och välfärd, Effekter av datoriserat beslutsstöd på klinisk praxis och patientresultat i prevention och behandling av trycksår och undernäring på sjukhem.
Identifiers
URN: urn:nbn:se:du-5612DOI: 10.1097/NCN.0b013e3182148c31ISI: 000296611000008PubMedID: 22041791OAI: oai:dalea.du.se:5612DiVA: diva2:520378
Available from: 2011-06-27 Created: 2011-06-27 Last updated: 2015-06-16Bibliographically approved

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CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • chicago-author-date
  • chicago-note-bibliography
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf