The changing healthcare environment today puts pressure on the computerization of patient records. For nursing activities to be included in the computerized patient record (CPR), there are two requirements: a standard nursing language with sufficient granularity, and a database that allows multiple data collection at once. Data completeness is a concern in documentation systems. A descriptive method was used to examine nursing documentation in one CPR for the prevalence and content free text documentation in a structured nursing information system (NIS).
The results show that there is widespread use of narrative note (free text) fields in the house. Variability in usage that is not related to patient acuity may indicate idiosyncratic unit or individual documentation practices. These findings support the use quality management activities to improve documentation practices. They also point out areas for database enhancement and information systems development.