Developing a module for nursing documentation integrated in the electronic patient record.
Norway's regional teaching hospitals are working together on a project to develop an interdisciplinary electronic patient record (EPR). This paper presents the results of a project to develop nursing documentation as part of an integrated EPR to improve the quality and continuity of patient care. The project used a consensus process as a working norm. The most important result is that the five hospitals have agreed on a framework for nursing documentation, and on the main components that need to be implemented in the electronic patient record.
Hellesø
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Institute of Nursing Science, University of Oslo, Norway. ragnhild.helleso@sykepleievit.uio.no
Ruland
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CM
D003200:Computer User Training; D003266:Continuity of Patient Care / Q000458:organization & administration; D003299:Cooperative Behavior; D004282:Documentation; D004509:Education, Nursing, Continuing; D017408:Guidelines as Topic; D006751:Hospital Information Systems / Q000458:organization & administration*; D006755:Hospital Shared Services / Q000458:organization & administration*; D006784:Hospitals, Teaching / Q000458:organization & administration*; D006801:Humans; D007318:Inservice Training; D007373:Interinstitutional Relations; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D009664:Norway; D009737:Nursing Records; D010348:Patient Care Team / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D012984:Software; D017749:Total Quality Management / Q000458:organization & administration