An Interview and an Observation Study of Nurses and Student Nurses' Electronic Clinical Documentation Behaviors in a OB/GYN Nursing Ward.

Studies in Health Technology and Informatics(2016)

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摘要
This research was conducted to understand clinical nurses' and nursing students' current use of a clinical nursing information system to document their patient care activities in an OB/GYN nursing ward at a medical center in central Taiwan. A semi-structure interview and participant observation methods were used to gather the data. The results showed that the majority of participants regarded the clinical nursing information system as a useful system in terms of saving documentation time and improving communication among healthcare providers. This study provided some empirical evidence of the attitudes/behaviors of nurses and student nurses about electronic documentation. However, more studies were recommended to evaluate the impact of electronic nursing documentation on the quality of care delivered to patients.
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关键词
Nursing documentation,clinical information system,electronic medical record
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