An analysis of narrative nursing documentation in an otherwise structured intensive care clinical information system.
Most structured nursing documentation systems allow the entry of data in a free text narrative format. Narrative data, while sometimes necessary, cannot easily be analyzed or linked to the structured portion of the record. This study examined the characteristics of free text narrative documentation entered in an otherwise structured record utilized in a cardiovascular intensive care unit. The analysis revealed that nurses documented 31 categories of narrative entries. Approximately 25% of these entries could have been entered into the structured portion of the record through the use of existing documentation codes. Nurses most frequently used the narrative documentation as a means to communicate summarized information for the coordination of healthcare team members. Development of tools to summarize structured data into an 'at a glance' format could enhance the coordination of healthcare team functioning. The authors discuss these results in the context of developing strategies to increase structured documentation and decrease free text in the patient record.
Moss
Jacqueline
J
School of Nursing, University of Alabama, Birmingham, USA.
Andison
Margot
M
Sobko
Heather
H
D001026:Coronary Artery Bypass; D003325:Coronary Care Units; D004282:Documentation / Q000379:methods*; D006751:Hospital Information Systems; D006801:Humans; D016347:Medical Records Systems, Computerized; D033262:Narration; D009737:Nursing Records