|
KMID : 0603720160220040270
|
|
Journal of Korean Society of Medical Informatics
2016 Volume.22 No. 4 p.270 ~ p.276
|
|
|
Factors Associated with the Timeliness of Electronic Nursing Documentation
|
|
Ahn Mee-Jung
Choi Mo-Na
Kim Young-Ah
|
|
|
Abstract
|
|
|
Objectives: To investigate the factors associated with the timeliness of electronic nursing documentation using the entrytime on the Electronic Medical Record (EMR) system.
Methods: As a retrospective study, data were extracted from January1 to February 28, 2014 from a hospital EMR system and a nurses’ personnel information system. The timeliness of instancesof nursing documentation was categorized into ‘timely’ or ‘untimely’ according to whether the entry time was time-stampedwithin the working hours during each day, evening, or night shift. Factors associated with the timeliness of the electronicnursing documentation were included in the logistic regression models as nurse- and patient-associated factors.
Results:Among 1,700,247 instances of electronic nursing documentation, 79.3% (n = 1,347,711) were completed within the workinghours. Years of nursing experience, nursing shift, days of the week, patients’ age, and medical department had a statisticallysignificant associated with the timeliness of nursing records. Nurses with experience of more than 1 year entered nursingrecords over 2 times more during their working hours than did less experienced nurses. During the evening and night shifts,nurses were 1.49 times and 9.19 times more likely to enter nursing documents in a timely manner, respectively, as comparedto those in the day shift.
Conclusions: Nursing documentation was typically completed outside of working hours when anurse had little experience, worked during the day shift or weekdays, and when tasks were unpredictable. This shows thatnew nurses need support to familiarize them with various tasks and the overall workflow.
|
|
|
KEYWORD
|
|
|
Electronic Health Records, Nursing Process, Nursing Records, Nursing Informatics, Documentation
|
|
|
FullTexts / Linksout information
|
|
|
|
|
Listed journal information
|
|
  
|
|