Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing

Abstract

Purpose

The purpose of this study was to describe and evaluate whether nurses have documented patient care in compliance with the national nursing documentation model in electronic health records, which means the use of the nursing process and the use of standardized terminology in different phases of the nursing process.

Methods

The data were collected from a central hospital in 2003–2006. The data consist of the electronic nursing care plans of 67 neurological patients and 422 surgical patients. The data were analyzed using statistical methods and content analysis.

Results

Standardized electronic nursing documentation is based on the nursing process, although the use of the nursing process varies across patients. There is a lack of progress notes relating to needs assessment, the identification of nursing diagnoses and care aims, and the nursing interventions planned in the documentation. The standardized terminology is used in the documentation but inconsistencies emerge in the use of the different classifications.

Conclusion

The national model for electronic nursing documentation is suitable for the documentation of patient care in nursing care plans. However, health care professionals need further training in documenting patient care according to the nursing process, and in using the terminology in order to increase patient safety and improve documentation.

Introduction

An electronic health record (EHR) is a source of information in patient care. Here, an EHR refers to an information repository where patient data are stored in digital form. It contains retrospective, concurrent, and prospective information and its primary purpose is to support continuing, efficient and quality integrated health care [1]. The delivery of good care and the ability to communicate effectively about patient care depends on the quality of information available to all health care professionals and between health care sectors. One important part of this information is nursing documentation in nursing care plans [2]. A nursing care plan is a part of electronic health record e.g. [2], [3], [4] as one data component of EHR system or a separate computerized nursing care plan system. Electronic nursing care plans have been used and developed for a long time but the use of standardized electronic nursing care plans is not so common. In standardized electronic nursing documentation, the structure of documentation includes the use of nursing process and use of standardized terminologies in the different phases of nursing process [5]. The benefits of the use of standardized nursing care plans have been proven. The evaluation of the content of standardized electronic nursing documentation is crucial in order to reuse valid data to measure patient outcomes [6].

The nursing process has long been used as a framework for nursing and nursing documentation. The nursing process model involves assessing, planning, implementing and evaluating patient situations, with the ultimate goal of preventing or resolving problematic situations [7]. In electronic nursing documentation, the phases belonging to the nursing process have varied in practice. According to earlier studies, electronic nursing documentation included at least needs assessment, determining the nursing diagnoses and care aims, planning and delivering nursing interventions, and the evaluation of outcomes [3], [4], [8], [9], [10], [11], [12], [13], [14], [15]. Earlier studies have reported that nursing documentation has conformed to the nursing process [13], and the use of the nursing process has been shown to improve legislative compliance and completeness of nursing documentation [3]. On the other hand, studies have also reported deficiencies in nursing documentation according to the nursing process [4], [12], [15], [16]. Even if all phases of the nursing process have not been documented in the EHR system, the nursing care plans have been updated more frequently using the EHR system compared with paper-based nursing care plans [4].

In addition to the use of nursing process, classifications are needed in order to standardize nursing documentation [17]. Various nursing terminologies have been developed and validated by nursing researchers e.g. [18], [19], [20]. Furthermore, different classifications such as the International Classification of Nursing Diagnoses (NANDA-I), the International Classification for Nursing Practice (ICNP), the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) have been used for the purposes of electronic nursing documentation in practice [5], [6], [21], [22], [23], [24]. According to earlier studies, the systematic collection of nursing data in the EHR system has shown benefits. The use of different terminologies and codes in nursing documentation enables the data to be utilized in care planning and decision making in patient care as well as in clinical research, health care management, health services planning and goverment reporting [21], [25], [26], [27], [28]. Standardization of nursing diagnoses and nursing interventions for documentation purposes has been shown to make the contribution of nursing visible and quantifiable [11], [21], [22], [23], [29], [30], [31], [32], [33].

The Finnish Model of Standardized Nursing Documentation which is based on the WHO nursing documentation model and use of Finnish Care Classification (FinCC) has been developed for national purposes [34] as a part of the national EHR project in Finland. The national standardized nursing documentation model has been implemented in different EHR systems which are in use in the public and private sectors in Finland. In the public sector, these EHR systems are used in primary, secondary, and tertiary care. The recommendation is to document according to the national standardized nursing documentation model despite of level of care or care specialty. EHR systems do not force nurses to document according to standardized nursing documentation model and it is possible e.g. in emergency cases to record the performed nursing interventions first and nursing diagnoses afterwards. It has also been recommended that vendors link nursing diagnoses, nursing interventions and outcomes of care to each other in the EHR system so that afterwards care can be tracked with the help of the nursing process [35].

The standardized nursing documentation model consists of four phases of the nursing process: needs assessment, determining of nursing diagnoses and nursing care aims, planning and delivering nursing interventions, and the evaluation of outcomes and terminologies used (Fig. 1). The needs assessment phase of the nursing process includes the patient's health data. This is done by the nurse who examines the patient and discusses with him/her. The phase of the nursing process for determining of nursing needs and nursing care aims comprises nursing diagnosis and aims for care, and expected outcomes are based on assessment data. Nursing diagnoses and aims for care are documented using the Finnish Classification of Nursing Diagnoses (FiCND). The phase of planning and delivering nursing interventions of the nursing process consists of optimally planned and delivered interventions to achieve expected outcomes. Both planned and delivered nursing interventions are documented using the Finnish Classification of Nursing Interventions (FiCNI). The phase of evaluation of outcomes includes the outcomes of nursing care achieved. The outcomes are documented using the Care Components of the FiCND, and an assessment made as to whether or not the outcomes of care were met using the three qualifiers: improved, stabilized or deteriorated e.g. [35], [36]. The model for the Finnish Nursing Documentation also includes the intensity of care documented using the Finnish Oulu Patient Classification e.g. [37], and the discharge summary combining the essential data of the care episode.

The FiCND and the FiCNI are based on Clinical Care Classification. The FiCND 1.0 consists of 17 Care Components, 45 major categories, and 101 subcategories of nursing diagnosis, and the FiCNI 1.0 consists of 17 Care Components, 111 major categories, and 262 subcategories of nursing interventions. Different levels of the terminology can be used for documenting nursing care. In the EHR system, narrative text can also be added to the documentation. The cultural development work of these classifications has been done over a period of many years and the need for further validation has been recognized [39]. The data elements i.e. nursing diagnoses, nursing interventions, and nursing outcomes of this model generate the nursing minimum data set (NMDS) in databases. The use of terminologies facilitates the retrieval of data from databases for managerial and administrative purposes along with other clinical data e.g. core data of EHR [40].

The use of the FiCNI for documentation purposes has previously been studied with reference to specialized care [41], [42], [43], [44]. According to the results of these studies, nursing interventions were documented using all FiCNI Care Components, and almost all major categories and subcategories of the FiCNI were used. The use of FiCNI Care Components and categories differed significantly between wards [41]. A study on the use of the FiCNI in documenting medication administration showed that the Medication Component, main categories and subcategories, had indeed been used. The most frequently used intervention was Medication Administration per os, and in almost all cases the intervention was complemented with narrative text concerning dosage and route [43]. Furthermore, the nursing discharge summaries included nursing diagnoses, nursing interventions and outcomes of care, and all the Care Components of FiCNI were used [42]. The FiCNI has moreover been found suitable for the documentation of wound care [44]. Studies have also shown a need for further development of FiCNI [41], [44].

Previous studies have emphasized the need for further studies focusing on the content of EHRs [5], especially studies of nursing documentation [2], [5]. The purpose of this study was to describe and evaluate whether nursing care is documented in compliance with the national nursing documentation model in the standardized electronic nursing care plans by evaluating and comparing nursing documentation between neurological and surgical care specialties. This study aims to answer to the following questions: 1. To what extent do nursing diagnoses, aims for care, nursing interventions and nursing outcomes appear in the standardized electronic nursing care plans? 2. To what extent does nursing documentation corresponds to nursing process model? 3. How are the aims for care, nursing interventions and outcomes of nursing care related to the nursing diagnosis? 4. How does the nursing documentation differ between neurological and surgical care specialties?