Model of Electronic Nursing Care Record for Patients with Vascular Access Malfunction

Background: Electronic documentation of nursing care data requires unified documentation, data standards, adequately accessible information technology and existing legislation. The aim of the study was to determine the role of electronic nursing care record in evaluation of patients with vascular access malfunction. Methods: Ten hospitalized patients with end-stage renal disease were enrolled in our study. Five nurses evaluated patients' problems with vascular access using the model of electronic nursing care record for nursing diagnosis of vascular access malfunction. The model has been tested with mobile device - tablet computers. After the patients conditions were evaluated, interviews with nurses about functionality of the model of electronic nursing care record were performed. The answers were analyzed using SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis. Results: Our study shows that electronic nursing care record ensures an efficient evaluation of a patient for a single nursing diagnosis in all process phases of nursing care. Using electronic record, nurses systematically collect and manually enter data into a mobile device next to a patient's bed and therefore increase accuracy of nursing care record. The electronic record sufficiently includes all data about venous accesses and vital signs at a single access point. The screen of a mobile device enables quick access to information about patients' medical data and therefore quicker nurse's response. Conclusions: The results of our study encourage us to further develop electronic nursing care record also for other nursing diagnoses in the field of nephrology and to implement e-documentation in daily clinical practice.