Development and evaluation of a terminology-based electronic nursing record system.

The present study was conducted to develop and evaluate a terminology-based electronic nursing record system. The narrative nursing notes of 63 obstetric patients collected over 395 hospital days were decomposed and cross-mapped with the Korean version of the beta version of the International Classification for Nursing Practice (ICNP). The terminology-based nursing record system was developed with a terminology server to manage nursing concepts and nursing phrases, and a user application system to document nursing notes. The system was evaluated in two Korean hospitals by 20 nurses documenting nursing notes of 57 patients. Patterns were found in nursing notes reflecting the nursing process. A total of 14,727 phrases were used for documenting nursing notes, with these phrases consisting of 237 unique phrases. Among the 259 unique nursing concepts extracted from the 237 unique phrases, 103 concepts (39.8%) did not map onto the ICNP. The users were able to find nursing phrases with a success rate of 89.4%. The mean time required for documentation at each input session decreased significantly from 276 to 158 s as the users became more experienced.