title: Implementation of a next-generation electronic nursing records system based on detailed clinical models and integration of clinical practice guidelines.
abstract: OBJECTIVE
  The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system.
  
  
  METHODS
  A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system.
  
  
  RESULTS
  The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines.
  
  
  CONCLUSIONS
  An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
authors: College of Nursing, Seoul National University, Seoul, Korea. ; Research Institute of Nursing Science, Seoul National University, Seoul, Korea.
authors: Yul Ha
authors: YH
authors: Min
authors: College of Nursing, Seoul National University, Seoul, Korea. ; Systems Biomedical Informatics Research Center, Seoul National University, Seoul, Korea.
authors: Hyeoun-Ae
authors: HA
authors: Park
authors: Department of Nursing, Seoul National University Bundang Hospital, Seongnam, Korea.
authors: Eunja
authors: E
authors: Chung
authors: Department of Nursing, Seoul National University Bundang Hospital, Seongnam, Korea.
authors: Hyunsook
authors: H
authors: Lee
keywords: Computerized Medical Records Systems; Evidence-Based Practice; Nursing Records; Semantics