MENU ▼
Read by QxMD icon Read
search
OPEN IN READ APP
JOURNAL ARTICLE

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

Seonah Lee, Mi Yang Jeon, Eun Ok Kim
Computers, Informatics, Nursing: CIN 2019, 37 (5): 266-275
31094916
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, stakeholders at clinical, information technology, and administrative levels should cooperate closely to address adverse consequences from implementation of structured documentation and standardized nursing terminologies.

Comments

You need to log in or sign up for an account to be able to comment.

No comments yet, be the first to post one!

Related Papers

Available on the App Store

Available on the Play Store
Remove bar
Read by QxMD icon Read
31094916
×

Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"