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KMID : 0603720130190040301
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Journal of Korean Society of Medical Informatics
2013 Volume.19 No. 4 p.301 ~ p.306
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Implementation of a Next-Generation Electronic Nursing Records System Based on Detailed Clinical Models and Integration of Clinical Practice Guidelines
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Min Yul-Ha
Park Hyeoun-Ae
Chung Eun-Ja
Lee Hyun-Sook
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Abstract
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Objectives: The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system.
Methods: A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system.
Results: The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines.
Conclusions: An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
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KEYWORD
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Computerized Medical Records Systems, Nursing Records, Semantics, Evidence-Based Practice
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