Electronic nursing record system. Experience in a large cardiac rehabilitation depatment

From Jan 1st to Sept 30^th 2007, 1355 patients (pts) were admitted for a residential cardiac rehabilitation program. A nursing record system (NRS) may have a positive impact on nurse practice and improve pts management, particularly in large departments. To implement an electronic NRS, integrated in the Hospital Information System, to plan individual pts care and interventions, limit the error risk, document nurses workloads, and verify the efficacy of the rehabilitation process (outcome). Description. The electronic NRS has a modular structure, with different sections: 1) a core component (clinical data collection at pts admission, including Barthel score), 2) the nursing diagnoses scores with the automatic generation of individual care plans and daily planning of related nursing, 3) scheduling labs analyses, 4) generation of a discharge. The NRS is accessible through a personal account (login & password) on all desktops; laptops connected via a protected WLAN are also available for data collection and scoring at pts´ bed. Complete data were available in 99.7% pts. A cumulative workload of 69342 activities was recorded (average 51/pt); the workload was higher in the 77 pts (6%) admitted to ICU and in pts with > 75y. As outcome measure, the Barthel score (87.9 and 94.2 on admission and discharge, p<0.001)) and the NANDA score (from 3.1 to 1.3, p<0.001) improved. The electronic NRS had a positive impact on nursing management. The automatic generation of individual pts´ daily workplan reduced both the risk of error during therapeutical interventions and to miss activities due to lack in communication among operators. The possibility to have a detailed workload may be useful for better resources utilization. Finally, the automatic generation of a nursing discharge summary may be effective to improve the integration with the home care health system.