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Healthc Inform Res > Volume 14(2); 2008 > Article
Journal of Korean Society of Medical Informatics 2008;14(2):161-168.
DOI: https://doi.org/10.4258/jksmi.2008.14.2.161    Published online June 30, 2008.
Availability of Nursing Data in an Electronic Nursing Tecord System for a Development of a Risk Assessment Tool for Pressure ulcers
In Sook Cho, Ho Yeoun Yoon, Sang Im Park, Hyun Sook Lee
1Department of Nursing, Inha University, Korea.
2Department of Nursing, Seoul National University Bundang Hospital, Korea.

This study explored the reuse of data captured by nurses to support nursing decisions related to pressure-ulcer care.

METHODS: To examine the existence of coded data in an electronic nursing record system for the identified concepts, we used the electronic nursing documents of a teaching hospital in Gyeonggi-Do, in Korea. A surgical intensive care unit (SICU) was selected as the test unit due to the high incidence of pressure ulcers. The concepts were identified from literature review and refined through the involvement of staff nurses.

RESULTS: We found that 93.4% of the necessary concepts were matched semantically with data items at the input level of the electronic medical record system. Eighteen concepts (60%) were directly matched with the data variables of structured electronic nursing records. Five concepts (16.7%) were matched into more than two items. Including the standard nursing statements coded in Nurses' notes, five concepts were mapped more.

CONCLUSIONS: More than 90% of the concepts were matched successfully, which suggests that the secondary use of the routine data collected in an EMR system could be used to develop an automated risk assessment tool for pressure ulcers.

Key Words: Computerized Medical Records System, Electronic Nursing Records, Pressure Ulcer, Nursing Practice Data
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