title: An Interview and an Observation Study of Nurses and Student Nurses' Electronic Clinical Documentation Behaviors in a OB/GYN Nursing Ward.
abstract: This research was conducted to understand clinical nurses' and nursing students' current use of a clinical nursing information system to document their patient care activities in an OB/GYN nursing ward at a medical center in central Taiwan. A semi-structure interview and participant observation methods were used to gather the data. The results showed that the majority of participants regarded the clinical nursing information system as a useful system in terms of saving documentation time and improving communication among healthcare providers. This study provided some empirical evidence of the attitudes/behaviors of nurses and student nurses about electronic documentation. However, more studies were recommended to evaluate the impact of electronic nursing documentation on the quality of care delivered to patients.
authors.affiliation: School of Nursing, Chung Shan Medical University.
authors.forename: Yen-Chiao Angel
authors.initials: YC
authors.lastname: Lu
authors.affiliation: School of Nursing, Chung Shan Medical University.
authors.forename: Yen-Ju
authors.initials: YJ
authors.lastname: Lin
mesh_terms: D001291:Attitude of Health Personnel; D004282:Documentation / Q000706:statistics & numerical data*; D057286:Electronic Health Records; D006751:Hospital Information Systems / Q000706:statistics & numerical data*; D062527:Meaningful Use / Q000706:statistics & numerical data; D009726:Nurses / Q000706:statistics & numerical data*; D009737:Nursing Records / Q000706:statistics & numerical data*; D009775:Obstetrics and Gynecology Department, Hospital; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data; D013338:Students, Nursing / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D013624:Taiwan; D014600:Utilization Review