Abstract
Digitalizing the nursing process has become a trend in medical care. The purpose of this study was to evaluate implementation of the Standardized Computerized Nursing Process Documentation System and patient outcomes. We analyzed hospitalized patients' electronic health record database with a total of 19 659 patients in 2015. The analysis focused on nurses' selection of nursing care plans for patients with a high risk of falls or pressure injuries through admission assessments. The effectiveness of implemented nursing care plans following falls or pressure injuries was explored. The results reveal that 55% of the hospitalized patients had a risk of falling, and 27.85% of patients were at risk of pressure injuries. Patients receiving nursing care plan who experienced falls or pressure injuries were significantly higher than those without a nursing care plan (P <.001). This study could not provide direct evidence for the effect of nursing care plans on reducing the incidence of falls and pressure injuries, which may be attributable to patient characteristics. Furthermore, an analysis on data from 2007 to 2017 using a run chart revealed that the mean incidence rate for pressure injuries decreased, whereas that for falls remained stable. The results indicate that the system did not increase the occurrence of such incidences.
| Original language | English |
|---|---|
| Pages (from-to) | 573-582 |
| Number of pages | 10 |
| Journal | CIN - Computers Informatics Nursing |
| Volume | 37 |
| Issue number | 11 |
| DOIs | |
| State | Published - 1 Nov 2019 |
Keywords
- Electronic health record
- Fall
- Nursing care plan
- Pressure injuries