Incorporating Standardized Nursing Languages Into an Electronic Nursing Documentation System in Korea: A Pilot Study

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Abstract

PURPOSE:

The purposes of this study were to (a) develop and implement a standardized nursing languages-based electronic nursing documentation system in Korea, and (b) explore nurses' experience with NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification languages in relation to nursing workflow.

METHODS:

The system was developed by the research team and implemented in a tertiary hospital in Korea. Ten nurses used the system and interviews were conducted to explore nurses' experiences with the standardized nursing languages.

FINDINGS:

The most frequently used NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification were identified. Nurses' experiences with standardized nursing languages and how they impact nursing workflow were analyzed.

CONCLUSIONS AND IMPLICATIONS:

Obtaining valid and comparable data from this system will be critical in improving patient safety, quality, and evidence-based practice.

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