Research Into the Way of Writing Nursing Diagnosis in Electronic Medical Records

Sugiura, Misako

Monday, July 11, 2011

Misako Sugiura, PhD
Junko Okumura, MMI
Setsuko Maeda, MSN
Takako Takeuchi, MSN
Yayoi Watanabe, MSN
Kaori Nakajima, MMS
Toshinobu Kawai, PhD
Seiichiro Takami, MBA
Department of Nursing, Japanese Red Cross Toyota College of Nursing, Aichi, Japan

Learning Objective 1: The learner will be able to know the present situation of electronic medical/nursing recrods (in particular flow of nursing information).

Learning Objective 2: The learner will be able to know that the description of etiologic factors and signs/symptoms is necessary for nursing diagnosis which suits each patient.

Purpose: In Japan, the conversion of nursing information to electronic form is rapidly progressing, and the number of medical institutions which adopt nursing diagnosis is increasing in order to describe patients’ nursing problems in common terms. However, the use of nursing diagnosis largely depends on the ability of nurses of judging nursing diagnosis and on the way of producing the menu of electronic medical records. This research regards the ability of nursing diagnosis as a process, and shows how, in Japanese electronic records, diagnosis process in each level flows and contributes to the judgment of nursing diagnosis.

Methods: The researchers obtained an approval from the Ethics Committee of the A University. As regards research objects and methods, the researchers interviewed three persons in nursing departments responsible for electronic medical records in Japanese official hospitals and observed the introduced system.

Results: It is revealed from the research that the characteristics of each patient’ nursing diagnosis label are necessary for nursing practice which suits each patient. Nursing diagnosis label, its related factors and diagnosis categories should be written down in nursing records. Furthermore, it should be guaranteed to describe, as etiologic factors and signs/symptoms, factors and signs/symptoms of the patients rather than the list of defining characteristics and related factors described by the North American Nursing Diagnosis Association (NANDA).

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