Utilizing nursing standards in electronic health records: A descriptive qualitative study
Peer reviewed, Journal article
Published version
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https://hdl.handle.net/11250/3128143Utgivelsesdato
2024Metadata
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Originalversjon
Laukvik, L. B., Lyngstad, M., Rotegård, A. K. & Fossum, M. (2024). Utilizing nursing standards in electronic health records: A descriptive qualitative study. International Journal of Medical Informatics, 184, Article 105350. https://doi.org/10.1016/j.ijmedinf.2024.105350Sammendrag
Background
The electronic health record (EHR), including standardized structures and languages, represents an important data source for nurses, to continually update their individual and shared perceptual understanding of clinical situations. Registered nurses’ utilization of nursing standards, such as standardized nursing care plans and language in EHRs, has received little attention in the literature. Further research is needed to understand nurses’ care planning and documentation practice.
Aims
This study aimed to describe the experiences and perceptions of nurses’ EHR documentation practices utilizing standardized nursing care plans including standardized nursing language, in the daily documentation of nursing care for patients living in special dementia-care units in nursing homes in Norway.
Methods
A descriptive qualitative study was conducted between April and November 2021 among registered nurses working in special dementia care units in Norwegian nursing homes. In-depth interviews were conducted, and data was analyzed utilizing reflexive thematic analysis with a deductive orientation.