Availability of nursing data in an electronic nursing record system for a development of a risk assessment tool for pressure ulcers.
- Author:
In Sook CHO
1
;
Ho Yeoun YOON
;
Sang Im PARK
;
Hyun Sook LEE
Author Information
1. Department of Nursing, Inha University, Korea. insook.cho@inha.ac.kr
- Publication Type:Original Article
- Keywords:
Computerized Medical Records System;
Electronic Nursing Records;
Pressure Ulcer;
Nursing Practice Data
- MeSH:
Electronic Health Records;
Electronics;
Electrons;
Hospitals, Teaching;
Incidence;
Critical Care;
Korea;
Medical Records Systems, Computerized;
Nursing Records;
Pressure Ulcer;
Risk Assessment
- From:Journal of Korean Society of Medical Informatics
2008;14(2):161-168
- CountryRepublic of Korea
- Language:Korean
-
Abstract:
OBJECTIVES: This study explored the reuse of data captured by nurses to support nursing decisions related to pressure-ulcer care. METHODS: To examine the existence of coded data in an electronic nursing record system for the identified concepts, we used the electronic nursing documents of a teaching hospital in Gyeonggi-Do, in Korea. A surgical intensive care unit (SICU) was selected as the test unit due to the high incidence of pressure ulcers. The concepts were identified from literature review and refined through the involvement of staff nurses. RESULTS: We found that 93.4% of the necessary concepts were matched semantically with data items at the input level of the electronic medical record system. Eighteen concepts (60%) were directly matched with the data variables of structured electronic nursing records. Five concepts (16.7%) were matched into more than two items. Including the standard nursing statements coded in Nurses' notes, five concepts were mapped more. CONCLUSIONS: More than 90% of the concepts were matched successfully, which suggests that the secondary use of the routine data collected in an EMR system could be used to develop an automated risk assessment tool for pressure ulcers.
