Nursing Application Model

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I am a Ph.D. student. I am engaged in the development of an application model of nursing records. This work is supported by a Grant-in-Aid for Scientific Research. The content of my presentation is shown on the slide. As of 2015, 70 percent of hospitals with more than 400 beds in Japan have introduced electronic health recording system. It was induced by a national policy. The government has developed the strategy of information technology and information and communications technology since 2001. Based on this strategy, the goal to promote the electronic health recording system was shown on the field of health and medical care. The Japanese Nurse Association considers that nursing records show the thought and deeds of nurses. It says that they…show more content…
Therefore, I considered that it is necessary to clarify the appropriate way of nursing records in order to use them effectively. Our ultimate goal is to clarify the current situation of nurses' electronic health records from the three perspectives of nursing practice, education, and research in order to develop an application model of nursing records more effectively. This application model is intended not just to show the recorded content for improving the content of nursing records but to visualize the appropriate way of nursing records in order to use them for the practice, education, and research of nursing. As the first step, this research aimed to examine how to put nursing records in electronic health recording system for clarifying problems through the analysis of the appropriate way of recording nursing process. In this presentation I am going to talk about the content of inputted information and the tasks for its use about nursing diagnosis and plans through the assessment of nursing…show more content…
“The information peculiar to patients on nursing outcomes” were inputted as follows: 26 (74.3%) on 35 cases of the framework of 13 fields, 11 (50.0%) on 22 cases of the framework of 8 fields, and 11 (29.7%) on 37 cases of the framework of 9 fields. It is considered that there was no way to input data in free description on nursing outcomes, so that it cannot show evaluation viewpoint based on the state peculiar to patients. On nursing intervention it was possible to register standardized terms in the system. On nursing intervention it was possible to input data not only by selecting registered terms but also by inputting the data in free description. On 94 cases the terms of nursing intervention were used as follows: “nursing intervention classification” (NIC) (20, 21.3%), “terms standardized for each hospital” (64, 68.1%), and “free description of each hospital and each nurse” (10, 10.6%). On the selected nursing intervention it was possible to input “the information peculiar to patients” in free

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