Reviewing the evidence on nursing record systems

Urquhart, C. & Currell, R. (2005). Reviewing the evidence on nursing record systems. Health Informatics Journal, 11(1), 33-44. First appeared as a paper in iSHIMR2004, Proceedings of the Ninth International Symposium on Health Information Management Research, 15-17 June 2004, Sheffield, UK.

The aim of this paper is to examine the relationship between nursing practice and the recording of practice. Outlines the main findings of a Cochrane systematic review on nursing records, discussing the indications from the included studies that compared computerised nursing care planning with paper-based systems. Qualitative research on nursing records systems, and other survey evidence, is collated to answer questions on the format of the record (structured versus free text, for what type of practice), occasions when information exchange about nursing care may not, and should not be recorded formally, and the effective organisation of the nursing record. Concludes that more research is required to answer these questions, as it seems that computerisation does not always bring the expected benefits, and outcomes for patient care are not clear.

Peer reviewed