Reviewing the evidence on nursing record systems

Abstract

The aim of this article is to examine the relationship between nursing practice and the recording of practice. We outline the main findings of a Cochrane systematic review on nursing records, discussing the indications from the included studies that compared computerized nursing care planning with paper-based systems. Qualitative research on nursing records systems, and other survey evidence, is collated to answer questions on the format of the record (structured versus free text, for what type of practice), occasions when information exchange about nursing care may not and should not be recorded formally, and the effective organization of the nursing record. We conclude that more research is required to answer these questions, as it seems that computerization does not always bring the expected benefits, and outcomes for patient care are not clear.

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