Abstract

Introduction: Digital technology has a tremendous impact on all sectors of health care. The advent of Electronic Health Record (HER) in healthcare systems and clinical practice has led to a greater appreciation of the importance of nursing documentation data. The aim of our work was to identify the state-of-the-art of implementation of nursing minimum data sets in different countries, the millstones encountered and ways to determine Romanian healthcare community to widely adopt the electronic nursing documentation record. Methods: Our study is based on a literature review (1995-2019), including conference proceedings, enhanced by an oral survey conducted for public hospitals and two private hospitals in Romania. Results: In most hospitals from USA, Canada, UK and EU, Australia and New Zeeland the transition period from nursing paper records to EHR started years ago and is still an ongoing process. In England the Government has committed to making all records concerning patients and care services, digital, real-time and interoperable by 2020. In EU, regarding Nursing Minimum Data Sets (NMDS), the most advanced implementation is in Belgium. A comparison of different NMDS implementations has shown, besides differences in advantages and disadvantages, there is not a unified view on what data must be included. In Romania, the EHR is mainly based on Diagnosis-Related Groups (DRGs) and do not include nursing documentation data. Moreover, with one or two exceptions, there are no paper-based nursing files. Conclusions: Electronic nursing documentation records and NMDS become a must in the digital era. Though there are valuable operational implementations of NMDS at the level of several countries, data sharing requires a broader consensus regarding nursing standards and classifications of nursing diagnosis, interventions and practices. Systems like ICNP, NANDA, ICF, and ZEFP must be further developed and improved to allow cross-mappings and capturing of multi-cultural aspects. Regarding Romania, the first steps toward an electronic nursing record are to update the nursing curriculum in all medical universities to include standards and classification systems and examples of nursing documentation files.

Keywords

Nursing Documentation Record, Nursing Minimum Data Sets (NMDS), Nursing Informatics, Electronic Health Record (EHR)