title: Electronic nursing documentation in a paediatrics hospital: impact on quality of care by using OpenEHR, IHE and HL7.
abstract: The acuity of illness of sick children requiring care in hospital is increasing. There are many more children now with disabilities and complicated long term illnesses. Respiratory illness is the commonest cause of morbidity in young children. Nurses have a pivotal role in the anticipation of and/or early identification of the sick child with potential or actual respiratory failure through the assessment and measurement of the child's pattern of breathing, including rate, rhythm and effort. It should also be conducted and interpreted in association with other clinical assessments, for example cardiovascular. Record keeping is an essential part of nursing care because it details the patient journey through the healthcare process. Good quality record keeping can improve the quality of patient care and for this reason nurses must seek to ensure that their documentation practices meet high standards. Poor standards of documentation were a contributory factor in the failure to detect patients who were clinically deteriorating. In this article we searched for evidence whether electronic health records has positive impact on quality of nursing care and present our experiences with electronic nursing documentation in the field of respiratory assessment of the children and young people.
authors.affiliation: Paediatrics Hospital, Ljubljana, Slovenia.
authors.forename: Majda
authors.initials: M
authors.lastname: Oštir
authors.forename: Marinka
authors.initials: M
authors.lastname: Purkart
authors.forename: Anita
authors.initials: A
authors.lastname: Stih
authors.forename: Biljana
authors.initials: B
authors.lastname: Prinčič
authors.forename: Andrej
authors.initials: A
authors.lastname: Orel
mesh_terms: D057286:Electronic Health Records / Q000592:standards*; D057208:Health Level Seven; D055991:Health Records, Personal; D006776:Hospitals, Pediatric / Q000592:standards*; D009737:Nursing Records / Q000592:standards*; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D017524:Slovenia