Efforts to Record ‘Nursing Practice' in Electronic Medical Records: Proposal of Implementation by Nurses

Monday, July 11, 2011

Setsuko Maeda, MSN1
Misako Sugiura, PhD1
Junko Katsuragawa, MA1
Takako Takeuchi, MSN1
Yayoi Watanabe, MSN1
Hiromi Ota, BSN2
Mitsuko Miyazawa, BSN3
Masako Ejiri, BSN4
Toshinobu Kawai, PhD1
Seiichiro Takami, MBA1
(1)Department of Nursing, Japanese Red Cross Toyota College of Nursing, Aichi, Japan
(2)Nursing Department, Japanese Red Cross Nagoya Daiichi Hospital, Aichi, Japan
(3)Nursing Department, Nagano Red Cross Hospital, Nagano, Japan
(4)Nursing Department, Toyama Red Cross Hospital, Toyama, Japan

Learning Objective 1: The learner will be able to know the Japanese interface designs of electronic medical records used by Japanese hospitals.

Learning Objective 2: The learner will be able to know functions necssary for correctly recording nursing practice in the perspective unique to nursing.

Purpose: In Japan, the utilization rate of electronic medical/nursing records by nurses is increasing.  This research examines, in the perspective of nursing information, interface designs of electronic medical records used by three Japanese hospitals, and proposes implementation necessary for nursing practice.

Methods: The researchers obtained an approval from the Ethics Committee of the Japanese Red Cross Toyota College of Nursing.  As regards research objects and methods, the researchers interviewed three persons in nursing departments engaged in the introduction of electronic medical records in hospitals (official hospitals) and observed the introduced system.

Results: Nurses are specialists who rely on information, but database which can get hold of information on patients in the perspective of nursing and data flow which can record information have not been completed.  In progress notes, an interface design is necessary to write in descriptive records, such as “patients’ understanding and response”.