[Effects of a computer-assisted system for nursing care documentation on quality and quantity of nursing care documentation].
The University Hospital in Heidelberg has been gathering experience with the computer based nursing documentationsystem PIK since 1998. Its introduction on four pilotwards was systematically evaluated in an intervention study, gaining data to acceptance issues as well as to the quality of nursing documentation, as the nursing process is often not documented in an appropriate manner. Data to quantity and quality of nursing documentation before and after the intervention was gathered by means of a quality checklist, which was developed on the basis of an intensive literature review. To measure a difference in the quality of nursing documentation 20 documents from each of the four wards were assessed at the three assigned points of time by two nursing experts. The assessors stated a significant improvement in documentation quality due to the increase in formal completeness when documenting the nursing process. The content of the documentation as well as the individualization of the nursing care plan still need to be improved.
Mahler
Cornelia
C
Projektleitung PIK, Universitätsklinikum Heidelberg, Vossstrasse 2, D-69115 Heidelberg.
Ammenwerth
Elske
E
Tautz
Angelika
A
Wagner
Andreas
A
Eichstädter
Ronald
R
Hoppe
Bettina
B
D001292:Attitude to Computers; D004282:Documentation / Q000379:methods*; D005858:Germany; D006801:Humans; D016347:Medical Records Systems, Computerized; D009737:Nursing Records; D010347:Patient Care Planning; D010865:Pilot Projects; D011785:Quality Assurance, Health Care; D012984:Software