Effects of nursing record education focused on legal aspects at small and medium sized hospitals

Nursing records provide an account of the care and treatment given to a patient, providing a way to monitor progress and develop clinical histories. They allow for continuity of care by facilitating treatment and support [1]. They are an official communication tool for medical staff and an integral part of patient care, providing evidence of care for patients [2]. Nursing records are also used as basic data for healthcare policymaking, statistical analysis, research, education, and insurance claims [3]. Therefore, nurses are responsible for maintaining accurate records of the care they provide and are accountable if information is incomplete and inaccurate [4]. As electronic medical records are becoming more widely used, nursing records are also transitioning from paper to electronic formats. The expansion of electronic nursing records (ENRs) promotes better quality, completeness, and accuracy. Furthermore, electronic nursing records have allowed nurses to spend more time nursing patients since less time is required to write nursing records [2]. On the other hand, a study criticized that ENRs often fail to reflect individual patients’ personal nursing care because the records contain repetitive, standardized text. This threatens patient safety, revealing the negative side of ENRs [2,5]. Lee [6] reported that nursing records’ accuracy in ENRs was only 61.9%. Kang [7] found that while 94.9% of ENRs contained information about patients’ conditions and status, only 65.3% recorded nursing services provided to patients. The obstacles to writing nursing records are having several ORIGINAL ARTICLE ISSN 1225-9578 e-ISSN 2093-7814 https://doi.org/10.5977/jkasne.2021.27.2.152 JKASNE Vol.27 No.2, 152-162, May, 2021