Implementation of a Next-Generation Electronic Nursing Records System Based on Detailed Clinical Models and Integration of Clinical Practice Guidelines.
10.4258/hir.2013.19.4.301
- Author:
Yul Ha MIN
1
;
Hyeoun Ae PARK
;
Eunja CHUNG
;
Hyunsook LEE
Author Information
1. College of Nursing, Seoul National University, Seoul, Korea. hapark@snu.ac.kr
- Publication Type:Case Report
- Keywords:
Computerized Medical Records Systems;
Nursing Records;
Semantics;
Evidence-Based Practice
- MeSH:
Data Accuracy;
Evidence-Based Practice;
Humans;
Korea;
Medical Records Systems, Computerized;
Nursing Records*;
Nursing*;
Semantics;
Seoul;
Triplets
- From:Healthcare Informatics Research
2013;19(4):301-306
- CountryRepublic of Korea
- Language:English
-
Abstract:
OBJECTIVES: 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.
