Review Article
Volume 2 Issue 10 - 2020
Individualization Process of the Standardized Care Plan through an Electronic Health Record. A Qualitative Study
Mònica Castellà-Creus1*, Maria-Eulàlia Juvé-Udina2, Maribel González-Samartino3 and Pilar Delgado-Hito4
1Deputy Director of Nursing, Hospital Universitari Germans Trias i Pujol, Catalan Institute of Health, Badalona, Catalonia, Spain
2Assistant professor, Department of Fundamental Care and Medical-Surgical Nursing. Faculty of Medicine and Health Sciences, University of Barcelona, L’Hospitalet de Llobregat, Catalonia, Spain
3Unit Nurse Manager, Hospital Universitari de Bellvitge, Department of Health Information Systems, Catalan Institute of Health, L’Hospitalet de Llobregat, Catalonia, Spain
4Director and Professor, Department of Fundamental Care and Medical-Surgical Nursing. Faculty of Medicine and Health Sciences, University of Barcelona, L’Hospitalet de Llobregat, Catalonia, Spain
*Corresponding Author: Mònica Castellà-Creus, Deputy Director of Nursing, Hospital Universitari Germans Trias i Pujol, Catalan Institute of Health, Badalona, Catalonia, Spain .
Received: October 01, 2020; Published: November 07, 2020


Introduction: Understanding the method used by nurses in the individualization process of the Standardized Care Plan is essential to improve the delivery of nursing care and be more competent to know what patients need.

Aim: To describe the stages of the Standardized Care Plan individualization process used by nurses in acute hospitalization wards.

Method: A qualitative study in accordance with Strauss and Corbin’s Grounded Theory was undertaken. Theoretical sampling with maximum variation was used to select nurses from adult units in three hospitals. In-depth individual interviews, participant observation and a focus group discussion were employed to obtain data. Constant comparison was used for analysis. Open, axial and selective coding were performed until data saturation was reached.

Results: Thirty-nine nurses participated between in-depth individual interviews and a focus group. Additionally, the researchers carried out 65 hours of participant observation. The analysis allowed the emergence of a core category: “adapting the standard to patient’s needs” that describes the meaning of the Standardized Care Plan individualization process given by nurses. In addition, three thematic categories were also identified: “clinical reasoning”, “individualization attributes” and “instrumental procedure”. Clinical reasoning enables the nurse to decide the appropriate Standardized Care Plan according to the reason for admission and then adjust its elements according to the patient’s comprehensive assessment. Individualization attributes describes some characteristics of this process like the prioritization of the life-threatening diagnoses and willingness to involve the patient and family. Finally, this individualization process also includes an instrumental procedure that is used to reflect the individualization record in the Electronic Health Record.

Conclusion: All of these steps are necessary in order to deliver and record a delivery of care that takes into account the needs and preferences of the patient and their family through an individualized care plan.

Keywords: Electronic Health Records; Nursing Care Plans; Nursing Process; Nursing Records; Qualitative Research


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Citation: Monica Castella-Creus., et al. “Individualization Process of the Standardized Care Plan through an Electronic Health Record. A Qualitative Study”. EC Nursing and Healthcare 2.12 (2020): 09-20.

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