Expanding the scope of electronic nursing documentation

Abstract

Electronic nursing documentation is a vital part of the EPR (Electronic Patient Record) and HIS (Hospital Information System). Based on the accepted professional guidelines for nursing care, Croatian Nursing Council has developed a printed version of nursing documentation that consists of 14 different documents, describing daily patient care in detail. This printed version has served as a template for developing the advanced IT system e-Nursing, that has enabled hospitals to enrol in the parallel process of introducing the electronic version and abandoning the printed version of nursing documentation. In 2012, the e-Nursing system became also an integral part of “HeartWays” project for rehabilitation of cardiac patients, in order to expand the potential of connecting the system with Patient monitoring system and Assisted exercise functionality. The Assisted exercise functionality allows not only scheduling and planning of the exercise, but measurement of exercising efforts in real time and extensive reporting of results of the workout for users (patients) and for health professionals. It allows the nurse to monitor any patient remotely, e.g. at home, and has direct influence on the patient’s life quality and health. In this paper we will focus on KPI (Key Performance Indicators) that allow the nurse higher accessibility to patient information in order to achieve a higher level of patient care and make evidence based decisions in managing the patient in the hospital or at home.