A large amount of patient data is produced and documented in patient care. Health care professionals expect that this routinely collected patient data can also be used for secondary purposes such as measuring the quality of care or to gain new knowledge. Routine data needs to be documented in a standardized form, based on clinical terminologies, to allow this secondary use of data. In Austria, hospitals are currently moving from paper-based documentation to computer-based documentation, but parts of the documentation are still done in paper-based form or without using clinical terminologies, especially in nursing. This study aims to analyze the availability of standardized electronic patient data in nursing in Austria. We conducted an online survey of 32 senior nursing managers at 32 Austrian hospitals. The study showed that 79% of hospitals use electronic health records for nursing documentation, but only 29% of the nursing care plans are documented in a standardized way using standardized nursing classification systems such as NANDA-I.
Keywords: Electronic health records; secondary use of clinical routine data; standardized nursing terminology.