Building an innovation electronic nursing record pilot structure with nursing clinical pathway.
The nursing process consists of five interrelated steps: assessment, diagnosis, planning, implementation, and evaluation. In the nursing process, the nurse confronts a great deal of data and information. The amount of data and information may exceed the amount the nurse can process efficiently and correctly. Thus, the nurse needs assistance to become proficient in the planning of nursing care, due to the difficulty of simultaneously processing a large set of information. Thus, some form of assistance will be needed to help nurses to become more proficient in planning nursing care. Using computer technology to support clinicians' decision making may provide high-quality, patient-centered, and efficient healthcare. Although some existing nursing information systems aid in the nursing process, they only provide the most rudimentary decision support--i.e., standard care plans associated with common nursing diagnoses. Such a computerized decision support system helps the nurse develop a care plan step-by-step. But it does not assist the nurse in the decision-making process. The decision process about how to derive nursing diagnoses from data and how to individualize the care plans still remains in the mind of the nurse. The purpose of this study is to develop a pilot structure in an electronic nursing record system integrated with international nursing standards for improving the proficiency and accuracy of the plan of care in the clinical pathway process. The pilot system has shown promise in assisting both student nurses and beginner nurses. It also shows promise in helping experts who need to work in a practice area that is outside of their immediate domain.
Hao
Angelica Te-Hui
AT
Nursing School of Taipei Medical University, Taiwan, ROC.
Huang
Li-Fang
LF
Wu
Li-Bin
LB
Kao
Ching-Chiu
CC
Lu
Mei-Show
MS
Jian
Wen-Shan
WS
Chang
Her-Kung
HK
Hsu
Chien-Yeh
CY
D019091:Critical Pathways / Q000458:organization & administration*; D004059:Diffusion of Innovation; D008485:Medical Audit; D048108:Nursing Informatics; D012189:Retrospective Studies; D013624:Taiwan