The Structure and Content of the Nursing Component of a Pilot Electronic Health Record for the Cardiac Managed Clinical Network in Scotland

摘要

The development of a Portal for the Cardiac Managed Clinical Network (MCN) in Glasgow, Scotland, provided an opportunity to move towards a paperless environment for health care records. Nursing diagnoses within NANDA were ranked and 39 core to cardiac nursing identified. Appropriate nursing interventions and outcomes were grouped to form 'templates' adaptable to the individual. A system was proposed to facilitate the use of these templates to ease the process of producing care plans. However, this did no more than serve as an ideal. This exercise acknowledges the complexity of nursing activity and highlights the need to standardise protocols and procedures in nursing practice. It also illustrates the imperative for nurses to be actively involved in developing clinical systems fit for purpose.