This paper reflects on the standardization activities of nursing documentation. Even though nurses are the most important manpower in terms of collecting patients' data, nursing documentation have been overlooked in the process of developing electronic patients records. It is impossible to complete a computerized patient record system without including nursing documentation. Standardization of nursing documentation is the first step toward a computerized documentation system. In this study nursing documentation forms were gathered from 11 tertiary hospital with more than 500 beds in Seoul. Out of various nursing documentation, 9 essential forms were chosen to standardize. They are admission assessment, form, nursing treatment record, nursing care plan, discharge planning record, patient transfer record, clinical observation record, nursing treatment record, nursing progress notes, critical care flow sheet, and preoperative checklist Forms and data elements were reviewed and analyzed. It was learned that there is no one perfect from that could be used in any agency. Data elements were analyzed and standardized. Data elements to be included in each form were selected. Standardized forms were developed with the selected data element. Guideline outlining how to use each nursing form were developed. Now it is in the process of validating the forms and the guidelines at 240 nursing units at 8 tertiary hospitals. The results of the validation study will be incorporated in the final version of nursing forms and they will be introduced to general nursing population at an open forum to be held by Korean Nurses Association at the end of this year. This standardization activities will have a great impact on nursing practice, education, administration and research.
Checklist ; Critical Care ; Education ; Health Records, Personal ; Humans ; Nursing Informatics* ; Nursing Records* ; Nursing* ; Patient Discharge ; Patient Transfer ; Seoul ; Tertiary Care Centers

The purpose of this paper is to introduce standardization activities of nursing documentation for special nursing units following standardization efforts for general nursing units last year. Modified Delphi approach with expert panel was used to identify essential nursing documents and data set for each units. Expert panel was consisted of head nurses or charge nurses of each special nursing unit from 8 tertiary hospitals with more than 500 beds in Seoul. the secretary-general of Clinical Nurses Association and a faculty of College of Nursing. The exiting nursing forms of seven special nursing units, which include Emergency room, Intensive care unit, Operating room, Respiratory intensive care unit. Delivery floor. Nursery and Dialysis room, were analyzed and prototypes of the standard nursing forms and guidelines were developed. The clinical field test was done with the help of Clinical Nurses Association. At the field test 3.744 clinical staff nurses from 20 tertiary hospitals with more than 500 beds in Korea were involved and provided feedback. Finally public hearing was held and more than 600 nurses from 116 hospitals attended and provided feedback. Through these process consensus of nursing community was attained for standard documents and data items. The result is available at http://nursing.snu.ac.kr/standard/ through internet.
Consensus ; Dataset ; Dialysis ; Emergency Service, Hospital ; Hearing ; Intensive Care Units ; Internet ; Korea ; Nurseries ; Nursing* ; Nursing, Supervisory ; Operating Rooms ; Seoul ; Tertiary Care Centers