COMPUTERIZED NURSING DOCUMENTATION

Computerized Nursing Documentation

Computerized Nursing Documentation

Background

Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance. Studies, however, reveal surprisingly little evidence of the linkage between recordkeeping and these outcomes. The literature features multiple exhortations and case studies aimed at improving nurses' recordkeeping in general8-10 or for specific diagnoses. The computerized nursing deocumentation also reveals the tensions surrounding nursing documentation. These include: the amountof time spent documenting; the number of errors in the records; the need for legal accountability; the desire to make nursing work visible; and the necessity of making nursing notes understandable to the other disciplines (Urquhart, 2005, 33-44.).

Introduction

Nursing documentation is an important part of clinical documentation. Thorough nursing documentation is a precondition for good patient care and for efficient communication and cooperation within the health care professional team. Nursing care is usually oriented toward the so-called nursing process. The nursing process provides a systematic methodology for nursing practice (Darmer , et al. 2006, 525-34).

Paper-based documentation systems have been introduced to support nursing process documentation. Frequently, however, large investments in documentation efforts, low quality and limited general acceptance of the nursing process have been reported. Therefore; there have been some attempts and discussions about how to support the nursing process using computer-based documentation systems.

Motivation is essential for learning, and important success factors for new computer-based system are, therefore, users' motivation and acceptance of new ways of working (Sabo, et al. 2005, 145-53). User acceptance is often even seen as the crucial factor determining the success or failure of a new project. This paper concentrates on the question of what determines user acceptance of a new system.

History

Tools are needed to support the continuous and efficient shared understanding of a patient's care history that simultaneously aids sound intra- and interdisciplinary communication and decisionmaking about the patient's future care. Such tools are vital to ensure that the continuity, safety, and quality of care endure across the multiple handovers made by the many clinicians involved in a patient's care. A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care. Since recordkeeping systems serve multiple purposes (e.g., legal requirements, accreditation, accountability, financial billing, and others), a tension has arisen and is undermining the primary purpose of the record and instead fueling discontinuity of care, near-misses, and errors. Among the more specialized types of documentation is the plan of care, a requirement of the Joint Commission (Dellefield, 2006, 128-33.). Though planning and plans should facilitate information flow across clinician providers there is little generalizable evidence about their effectiveness.

Computerized Nursing Documentation Pors and Cons

The perceived pros of introducing computer-based nursing documentation practice are:

The respondents' perceived benefits of introducing computer-based nursing documentation practice include: time saving (76%); legibility (72%); reducing storage space and easy information retrieval (64%); 'Ease of use' (60%); reducing duplication, and is useful (50%); facilitating statistical ...