Development and evaluation of an electronic nursing documentation system

Introduction: nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reporting is described in scientific literature and care practice, and no uniform structured documentation is given. Aims This study aimed to describe the process of designing and evaluating the content of an electronic nursing documentation system to provide consistent and unified reporting in this context. Methods A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisting of two phases, as follows: A literature review was performed to attain an exhaustive overview of relevant elements of nursing and map the available evidence underpinning the development of the MDS. Second, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Next, the electronic nursing system (ENS) was developed according to the finalized MDS, and finally, its performance was evaluated by involved the end-users. Results The proposed MDS was divided into administrative and clinical sections; including nursing assessment and nursing diagnosis process. Then, a web-based system with modular and layered architecture was designed based on derived MDS. Finally, to evaluate it, a survey by participating 150 registered nurses (RNs) was conducted and the positive impacts and negative impacts of the system were identified. Conclusion The developed system is suitable for the documentation of patient care in nursing care plans. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.