Evaluating the impact of computerized clinical documentation.
A computerized system for care planning and documentation of patient care was initiated at a western teaching hospital, using the framework of Nursing Interventions Classification and Nursing Outcomes Classification standardized languages. The software integrates care planning and documentation, and includes both order entry as well as a charting application. Prior to initiating the project, a study was conducted to evaluate staff attitude toward computerization, time needed for documentation, and comprehensiveness of charting entries. Data from staff surveys, observations, and chart audits conducted pre- and post-computer project implementation demonstrated that the staff attitudes toward computers were less positive, the time required for charting was unchanged, and there were improvements in how completely the nurses documented charting elements.
Smith
Kathy
K
University of Colorado Hospital, Denver, CO 80262, USA. Kathy.smith@uch.edu
Smith
Vivienne
V
Krugman
Mary
M
Oman
Kathleen
K
D000328:Adult; D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D003200:Computer User Training; D004282:Documentation / Q000592:standards*; D004509:Education, Nursing, Continuing; D005260:Female; D006801:Humans; D007318:Inservice Training; D008297:Male; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009730:Nursing Assessment; D009731:Nursing Audit; D015403:Nursing Evaluation Research; D015404:Nursing Methodology Research; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital / Q000193:education / Q000523:psychology; D010347:Patient Care Planning; D010865:Pilot Projects; D011795:Surveys and Questionnaires; D013997:Time Factors; D018875:Vocabulary, Controlled