When patients are in hospital or sick at home and visited by a nurse, it is important that the care they receive is recorded properly. Nurses record a wide variety of information about a patient’s care and progress. For example, nurses would record a patient’s status while in ICU every hour, or when and how pain medication should be given and when it was given, or the progress of a pregnant woman visiting a clinic. These nursing records are a way for nurses to share care information with other nurses, other health care professionals and sometimes with patients. This is Information that can ensure patient care is consistent when staff changes shifts or information that can be used later as a history of previous care.
But what is the best way to record and share this information? Is there a system or way of recording care information that is best? It has been suggested that there may be a difference in how nurses practice or how well a patient does with the use of one record system compared to another.
A review of the effect of different nursing record systems was conducted. After searching for all relevant studies, 9 studies were found. These studies compared nursing records filled out on paper with nursing records done on computer; nursing records that were held by patients themselves to records kept at a hospital or clinic; and nursing records which used different types of forms.
The evidence shows that nursing record systems which aim to fix a specific problem, such as reducing lost notes, decreasing the time required for data entry, or the amount of paper files, may be successful at fixing that problem. But it is uncertain whether changing an entire system of recording nursing care may improve how nurses practice or how well a patient does.
What this review did show, is that there needs to be more work with the nursing professions to understand exactly what needs to be recorded and how it will be used, and that it is important to involve the nursing staff in the design and development of the nursing record systems.