Clinical recording is the basis and essential element of all medical encounters. Its accuracy and precision can show the quality of care and services provided and the condition of the patient's illness.1 Since the clinical record contents provide a consistent basis for medical treatment, all aspects of the clinical record must be completed and then can be utilized among the various therapists, including physicians and nurses.2 As any other aspect of healthcare, clinical documentation has been affected by technological advancement, a typical example of which is electronic health records (EHRs) in recent decades.3 Along with other healthcare data relevant to patient care, EHRs are defined as electronic versions of patient healthcare histories that contain key administrative healthcare data.4 They have been considered a digitized record of the patient condition that appears to be a partial or complete substitution of paper records, and they have emerged as a promising tool to improve healthcare quality.3 It was suggested that EHRs may improve documentation to increase the accuracy and completeness of patient data. They can also enhance the ability of physicians and nurses to properly diagnose and treat patients.5 In EHRs, timely and accurate patient risk assessment and quality measurements are also allowed to intervene more rapidly as needed.6 Finally, many EHRs include tools to support clinical judgment and decision making, as well as care coordination and the exchange of healthcare information.7 There are many merits of EHRs, which indicates why their adoption rate has been high. The global transition from paper to electronic documentation has been expanding, and South Korea is joining this trend. In Korea,8 years have passed since the introduction of electronic medical records in 2005; the overall application rate in hospitals in South Korea was an average of 20.7% in 2005,9 while that of EHRs has reached 71.3% in 2015 in South Korea, although it depends on the size of the hospital.10 Furthermore, the Korean government is pushing for a medical information exchange project to facilitate an emerging big data platform of medical information among medical institutions as the next step of a nationwide initiative.10
The application of electronic medical records has also had a significant impact on nursing practice. Nursing records are important, and appropriate documentation is essential as a quality assurance tool. Its importance is also growing.11 In recent years, there have been significant changes in the Korean hospital nursing care delivery system under government guidance. It is called "comprehensive nursing service" since it is a nursing delivery system that provides complete nursing services, including caregiving, by only nursing staff. One of the important characteristics of hospital care in Korea is the involvement of family caregivers in inpatient care. Therefore, family or paid caregiving, even for inpatients, is taken into account when designing and delivering nursing care.12 For these reasons, it could be possible for a small number of nurses to care for a large number of hospitalized patients over 50 years (one nurse to 15-20 inpatients on average). However, this pre-existing system has caused many socioeconomic problems, such as the cost of caregiving and quality issues provided by private paid caregivers. Therefore, the Korean government introduced a comprehensive nursing and caregiving service model in which one nurse performs holistic nursing for 8 to 12 patients without family members or private paid caregivers as a pilot project since 2014. This comprehensive nursing and caregiving service has almost doubled from 7000 beds in 2015 to 15 000 beds in 2016 and has expanded its size nationwide to 23 000 beds in 2017.13 It is especially important that this new nursing care delivery system has resulted in changes in the nursing profession's scope of practice. For example, nurses directly assist and care for patients in all activities of daily living (ADLs).12 These important changes in nursing practice should be identified in the nursing documentation. Therefore, it is necessary to identify how well each of the large changes in nursing practice influences the comprehensive nursing service. Efforts to identify these changes will also be made to check the effectiveness of the EHRs over 10 years in Korea.
Purpose
This study aimed to assess how well the electronic nursing record reflects nursing services that are being used differently. In particular, this study aimed to evaluate recent changes in the nursing profession's scope of practice in Korea, including changes in patient care involving ADLs (Figure 1).
Study Setting
The hospital in which this study was conducted was a general hospital with 200 beds in Seoul, South Korea. There were a total of three comprehensive nursing service wards, containing 111 beds (55.5% of total hospital beds). One of the three wards started the comprehensive nursing service in November 2016, the second in August 2017, and the third in February 2018. Two general service wards, in which comprehensive nursing service had been implemented for more than 3 months, were the setting for the study. For instance, one ward added three more nurses while implementing the comprehensive care with 44 beds and 20 nurses. The number of nurses per shift was five for the day shift, five for the evening, and four for the night shift. Before implementation of the comprehensive nursing service, four, four, and three nurses operated per shift.
Data Collection
The analysis targeted 100 records of patients using the random sampling method for a total of 508 patients who were hospitalized from November 1 to November 30, 2017 in the two wards of the comprehensive nursing service. In addition, the analysis targeted 100 of the total 368 patients in the general ward of the control group who were hospitalized in two general wards from November 1 to 30, 2017 to examine data from the same period in order to represent the seasonal characteristics. The wards studied were for obstetric, general surgery, urology, and digestive diseases patients. The nursing records of the studied hospital use a system for electronic medical records. The electronic nursing records are also developed to facilitate recording by nurses and categorized as "clinical observation records," "nursing activity records," and "nursing records." All of these are subject to analysis in this study. The first category, "clinical observation records," includes the records of physical measurements, vital signs, pain assessments, and eating. The second category, "nursing activity records," includes nurse rounding, fall prevention, urination rounding, oral administration of medication, and skin assessment (Figure 1). In this study, the number of nursing records for each of these categories was analyzed. Nursing records, the third category, are those in which nurses write about patient care including a nursing diagnosis. Thus, this study analyzed a total of 19 372 nursing records for 100 patients in the comprehensive nursing service ward and 100 patients in the general ward, for a total of 200 hospitalized patients. Since this study is a secondary data analysis based on patient records, it was only possible to collect data in the studied hospital. The personal information of all collected data was thoroughly coded during analysis.
Data Analysis
The collected data were analyzed at the .05 level of significance using the IBM SPSS Statistics v 23 (IBM, Armonk, NY). The general characteristics of the comprehensive nursing service ward patients were analyzed as numbers, percentages, means, and SDs, and the analysis was performed as a [chi]2 test. In addition, the average difference in the number of nursing records was analyzed by an independent t test.
RESULTS
Descriptive Statistics of General Characteristics
As shown in Table 1, the mean age of patients in the comprehensive nursing service ward was 40.40 +/- 13.16, and that in the noncomprehensive nursing service ward was 37.71 +/- 9.15. Among the patients in the comprehensive nursing service ward, 11 were men, and 89 were women. In addition, in the noncomprehensive nursing service ward, seven were men, and 93 were women. The average number of hospital days spent in the comprehensive nursing service ward was 4.57 +/- 3.66 and 4.13 +/- 2.06 in the noncomprehensive nursing service ward. Among the patients in the comprehensive nursing service ward, 64 were obstetric gynecology patients, 15 were general surgery patients, eight were urology patients, six were infectious disease patients, and seven were internal medicine and dental surgery patients. In the noncomprehensive nursing service ward, 77 were obstetric gynecology patients, seven were general surgery patients, three were urology patients, 10 were infectious disease patients, and three were internal medicine and dental surgery patients. There were no significant differences between the two groups based upon age, gender, number of hospital days, and clinical department. The homogeneity of the two groups was thus identified.
Differences in Nursing Records
Differences in nursing records are shown in Tables 2 and 3. There were more nursing activity records in all items for the comprehensive nursing service ward compared with the noncomprehensive nursing service ward (Table 2). All but three items showed significant differences. As a result of the analysis of the clinical observation records, as shown in Table 3, the mean of records in the comprehensive nursing service ward for "diet (P = .049)" and "Foley catheter monitoring (P = .029)" was significantly higher than in the noncomprehensive nursing service ward.
Differences in Nursing Diagnoses
As shown in Table 4, there were 23 types of nursing diagnoses used in the nursing records. Among them, five nursing diagnoses including "anxiety" (P = .007), "pain" (P = .001), "risk for bleeding" (P < .001), "lack of activity" (P = .003), and "disturbed sleep pattern" (P = .011) were used significantly more in the records of the comprehensive nursing service ward than in records of the noncomprehensive nursing service ward.
DISCUSSION
This study aimed to determine how well electronic nursing records reflect nursing services that are being used differently, focusing on comprehensive nursing care service as a new nursing care model. As a result, the ultimate purpose of this study is to assess how well the electronic nursing record shows changes in nursing performance. Based on this study, there were differences in nursing performance between the comprehensive nursing service ward and the noncomprehensive nursing service ward. The results of this study are similar to those of earlier studies8,12 on the application of the comprehensive nursing care service.
In this study, three types of nursing records were analyzed. The first was the record of nursing activities, the second was clinical observation, and the third was nursing diagnosis. The most noticeable difference among the three types of nursing records between the comprehensive nursing care service ward and the noncomprehensive nursing care service ward involved the record of nursing activities. Through comparison analysis, it was found that there were significant differences between the two groups in all but three items. Table 2 shows that there were more nursing activity records for all items of the comprehensive nursing service ward. For the noncomprehensive nursing service ward, many items, such as "nurse rounding" and "skin assessment," had no records. In contrast, there were many records-related items in the comprehensive nursing service ward. It is not known whether the nurses performed the nursing activities but did not create a nursing record or whether the noncomprehensive nursing service ward did not have a policy of creating records for the items with no record. The EHR system, which allows nurses to record the details of patient care, is basically the same for both wards: nursing activity records and nursing records. However, more data fields were added to the EHR for the comprehensive nursing service ward, because of the new nursing activities that had not been performed on the general ward (eg, meal assistance, exercise assistance, hair shampooing, and tube feeding). Because nursing departments had specific data entry fields in the EHR for the comprehensive nursing service ward, the differences may have been due somewhat to the structure of the EHR rather than to the nursing care provided. What is certain, however, is that nursing activities that nurses did not perform at all in the noncomprehensive nursing service unit have been identified in the comprehensive unit nursing records. Strictly speaking, there are some nursing activities that may have been performed in the noncomprehensive nursing service ward but were not recorded (eg, nurse rounding and skin assessment), but the new nursing activities in the comprehensive unit are identified in the records, and these nursing activities are not included in the job descriptions of the noncomprehensive unit nurses. Therefore, based on these findings, the purpose of this study is to assess the resulting changes in nursing activities.
The noncomprehensive nursing care system is where the caregiver (eg, family member) is present in the patient's room and is responsible for the primary care of the patient (eg, meal assistance, exercise assistance, and hair shampooing), which is not reflected in the nursing record. On the comprehensive nursing services ward, primary care is performed by a member of the nursing staff, and this is recorded. Therefore, the initiation of a new system of the comprehensive nursing care service is reflected in nursing records. Further research is required to determine whether nurses on the noncomprehensive nursing service ward performed certain activities, but they were not recorded, or the nurses had not performed these activities. However, the difference analysis for the two wards confirmed that there were significant differences.
Nonetheless, three nursing activities-"description of the examination," "management and prevention of pressure ulcer," and "education for fall prevention"-did not create a difference between the two groups. Among these, the noncomprehensive nursing care service ward had more records for "education for fall prevention." This is possible since one of the comprehensive nursing care service ward's records contains information on fall education in "nurse rounding," for example. In fact, "nurse rounding" of the comprehensive nursing care service ward mainly deals with assessing and preventing fall risks for patients by referring to the operating instructions.14 No significant difference was found between the two groups for the "management and prevention of pressure ulcer" record. In this case, similar to the "education for fall prevention" record, it is possible since one of the comprehensive nursing care service ward's records contains information on pressure ulcer prevention, such as "skin assessment." It should be noted that the record of "description of the examination" showed no significant difference between the two groups. "Description of the examination," as with other items, is recorded in nursing records. The term refers to the process in which a nurse provides the patient with a description of the examination to be performed. On the comprehensive nursing care service ward, the nurse is the patient's primary care provider and may be in the best position to deliver the information. A qualitative study of nurses in the comprehensive nursing care service ward showed that there are positive aspects of more patient education and explanation and expected the responsibilities of nurses in the comprehensive nursing care service ward to grow in that regard.15 In other words, it can be expected that the duties of nurses in the comprehensive nursing care service ward with regard to patient education and emotional support will increase; however, there was not much difference in nursing records between the two groups. This can be seen in the analysis of differences of nursing diagnosis. Among the five nursing diagnoses that had significant differences between the two groups, only "anxiety" is associated with emotional conditions. This can be explained in two ways. First, it is assumed that sufficient assessment and diagnosis of the patient's emotional state are already being undertaken in the noncomprehensive nursing care service ward. However, this assumption may not be correct, based on the results of this study in which the number of relevant nursing diagnoses in the noncomprehensive nursing care service ward is very small. In the nursing record analysis, there was still not much patient emotional state assessment, education, or counseling and no difference between the two groups. Second, it may be that although more nurses have been added for the comprehensive nursing care service, they may still be insufficient to assess the emotional state of the patient or provide education. Regardless, it is true that current nursing records focus on simple nursing activities in terms of the comprehensive nursing care service, in which nurses provide all care directly on behalf of the family or paid caregivers.
Interestingly, as indicated in Table 4, a number of activities were more prevalent on the noncomprehensive nursing service ward, but the differences in the numbers for these activities were not statistically significant between the two groups. Further research is needed on this finding, especially for the comprehensive nursing care service ward. This research should also focus on promoting use of the nursing diagnosis record.
This study was not to confirm what was better and worse within the two nursing care systems, but to determine whether the characteristics of the changed nursing service were well reflected in the nursing record. It was confirmed that the comprehensive nursing service unit had more detailed records of patient safety and condition change than the noncomprehensive nursing service unit. On the noncomprehensive nursing service ward, some of these nursing activities were performed by nurses and some by family members. The activities that were performed by family members were not reflected in the nursing record, but some activities that were to be performed by the nurses (eg, "nurse rounding" and "skin assessment") were not recorded.
There are many possible explanations as to why some activities that were to be performed by the nurses were not recorded. The noncomprehensive nursing service unit has fewer nurses than the comprehensive nursing service unit, and although family members are responsible for the basic care of the patient, the unit provides nursing care with a small number of nurses. Nursing documentation is a reflection of nursing performance. Thus, there was a clear change in nursing performance, reflected in the change in the nursing record. Basic care by patient caregivers is not reflected in the nursing records, but the basic nursing performed by the nurse is reflected in the records, indicating that there has been a change in nursing performance.
It has been more than 10 years since we started using electronic nursing records. Since then, various studies have analyzed the use of these records.2,9,10,16-18 In addition to following the suggestions of these studies, such as standardized terminology, healthcare policy makers need to understand which organizational and environmental factors affect the adoption of EMR systems. It is also necessary to actively invest in and develop the nursing record system so that it can better serve as a tool for patient care and as a guide for decision making. To do so, examination at the microeconomic level is needed to better reflect the changes in nursing performance.
Limitations
The main limitation of this study is that data were collected on four wards of one hospital that were operating the comprehensive nursing care service and the noncomprehensive nursing service. As a result, there are restrictions on the generalization of the research results to other hospitals and wards. Another limitation is that a few data fields were added to only the EHR for the comprehensive unit, so the differences could have been in the structure of the EHR rather than in the nursing care provided. In terms of the nursing services provided, further research is needed to determine whether the nurse performed the nursing activity but it was not recorded or whether the activity is not on record because it was not performed.
CONCLUSION
This study aimed to assess how well electronic nursing records reveal nursing services that are being used differently due to changes in the nursing profession's scope of practice. The results of this study are that the numbers of nursing activity records for all items in the comprehensive nursing service ward were higher than in the noncomprehensive nursing service ward. All but three items showed significant differences. For instance, within nursing, diagnoses-"anxiety" and "pain"-were significantly used more in the comprehensive nursing service ward than in the noncomprehensive ward. The results of this study indicate that current electronic nursing record systems reflect changed nursing performance properly. Future studies should be conducted on how nurses can carry out nursing activities to better reflect the changes in nursing performance with nursing records while minimizing the time and effort required to record them.
References