Evaluation of nursing information before and after introduction of the electronic chart system

Abstract

Background and Objective: To determine the influence of introducing the electronic chart system on nursing information, the amount of information and its contents were evaluated on the basis of nursing records used before and after introduction of this system. Subjects and Methods: The nursing records were analyzed at the hospital into which the electronic chart system had been fully introduced. The subjects of the analysis were SOAP-formed nursing records on attribute-matched surgical patients. The data collected from 13 postoperative patients before introduction of the electronic chart system were compared with those obtained after the introduction. Results: There was no quantitatively significant difference between before versus after introduction in terms of diagnostic nursing care, related factors, nursing design, or time-course problems. According to the NANDA (North American Nursing Diagnosis Association) classification of 13 areas, the proportion of the data collected mainly in 4 areas before introduction was significantly higher than after introduction. The related factors were described by a unified expression before introduction, while being described by various expressions afterwards. Conclusion: There was apprehension about the possibility of the process of making diagnoses being stereotyped by the introduction of this chart procedure, but it was considered that indications for a list of candidate diseases to be diagnosed and selection with decision-making tended instead to expand logical thought processes and to be useful for making a plan which pays specific attention to databases.