A total of 244 days of pre- and postoperative narrative nursing notes of 20 open heart surgery patients and another 272 days of pre- and postoperative narrative notes of 20 open heart surgery patients documented by the surgical care and intensive care unit nurses before and after electronic nursing records was implemented were collected. Narrative nursing notes were decomposed into a single statement, analyzed and categorized according to its content, nursing process and level of abstraction.In terms of quantity of nursing record, the average number of statements documented per patient per day has increased by 15.3 statements, from 10.3 to 25.6 statements for electronic nursing record. The average number of redundancies of a unique statement also has increased by 67%, from 5.0 to 8.8 for electronic nursing records.

In terms of quality of nursing record, there were no nursing notes in a pattern of nursing assessment-nursing diagnosis-nursing action-nursing outcome and 0.2% of nursing notes in a pattern of nursing assessment-nursing action-nursing outcome before electronic nursing record was introduced. There were 0.1% of nursing notes in a pattern of nursing assessment-nursing action- nursing outcome and 3.1% in a pattern of nursing assessment-nursing diagnosis-nursing action-nursing outcome after electronic nursing records was introduced.

As for the content of nursing records, paper-based nursing records has more patient related problem statements describing signs and symptoms, nurse observations, and patient status and electronic nursing record has more nursing actions statements describing nurses’ activities.

In terms of granularity, the electronic nursing records have a more detailed documentation compared to the paper-based nursing records.