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Nursing record systems: effects on nursing practice and healthcare outcomes

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Abstract

Background

A nursing record system is the record of care that was planned or given to individual patients and clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.

Objectives

To assess the effects of nursing record systems on nursing practice and patient outcomes.

Search methods

For the original version of this review in 2000, and updates in 2003 and 2008, we searched: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; MEDLINE, EMBASE, CINAHL, BNI, ISI Web of Knowledge, and ASLIB Index of Theses. We also handsearched: Computers, Informatics, Nursing (Computers in Nursing); Information Technology in Nursing; and the Journal of Nursing Administration. For this update, searches can be considered complete until the end of 2007. We checked reference lists of retrieved articles and other related reviews.

Selection criteria

Randomised controlled trials (RCTs), controlled before and after studies, and interrupted time series comparing one kind of nursing record system with another in hospital, community or primary care settings. The participants were qualified nurses, students or healthcare assistants working under the direction of a qualified nurse, and patients receiving care recorded or planned using nursing record systems.

Data collection and analysis

Two review authors (in two pairs) independently assessed trial quality and extracted data.

Main results

We included nine trials (eight RCTs, one controlled before and after study) involving 1846 people. The studies that evaluated nursing record systems focusing on relatively discrete and focused problems, for example effective pain management in children, empowering pregnant women and parents, reducing loss of notes, reducing time spent on data entry of test results, reducing transcription errors, and reducing the number of pieces of paper in a record, all demonstrated some degree of success in achieving the desired results. Studies of nursing care planning systems and total nurse records demonstrated uncertain or equivocal results.

Authors' conclusions

We found some limited evidence of effects on practice attributable to changes in record systems. It is clear from the literature that it is possible to set up the randomised trials or other quasi‐experimental designs needed to produce evidence for practice. Qualitative nursing research to explore the relationship between practice and information use could be used as a precursor to the design and testing of nursing information systems.

Plain language summary

Nursing record systems to improve nursing practice and health care

When patients are in hospital or sick at home and visited by a nurse, it is important that the care they receive is recorded properly.  Nurses record a wide variety of information about a patient’s care and progress.  For example, nurses would record a patient’s status while in ICU every hour, or when and how pain medication should be given and when it was given, or the progress of a pregnant  woman visiting a clinic.  These nursing records are a way for nurses to share care information with other nurses, other health care professionals and sometimes with patients.  This is Information that can ensure patient care is consistent when staff changes shifts or information that can be used later as a history of previous care.

But what is the best way to record and share this information? Is there a system or way of recording care information that is best?  It has been suggested that there may be a difference in how nurses practice or how well a patient does with the use of one record system compared to another. 

A review of the effect of different nursing record systems was conducted.  After searching for all relevant studies, 9 studies were found.  These studies compared nursing records filled out on paper with nursing records done on computer; nursing records that were held by patients themselves to records kept at a hospital or clinic; and nursing records which used different types of forms.

The evidence shows that nursing record systems which aim to fix a specific problem, such as reducing lost notes, decreasing the time required for data entry, or the amount of paper files, may be successful at fixing that problem.  But it is uncertain whether changing an entire system of recording nursing care may improve how nurses practice or how well a patient does.

What this review did show, is that there needs to be more work with the nursing professions to understand exactly what needs to be recorded and how it will be used, and that it is important to involve the nursing staff in the design and development of the nursing record systems.