Improving nursing documentation to include outcomes of care in computerized information systems

Area of Science:

• Nursing Information Systems
• Healthcare Quality Improvement
• Patient Outcome Measurement

Background:

• Information system models often omit or isolate patient outcomes.
• Current practices may view outcomes solely as end-stage treatment results.
• Effective outcome evaluation necessitates integration across the care continuum.

Purpose of the Study:

• To describe a model for integrating patient outcomes in nursing care delivery.
• To identify nursing domains crucial for achieving desired patient outcomes.
• To enhance the evaluation of healthcare interventions through integrated outcome assessment.

Main Methods:

• Development of a conceptual model for nursing information systems.
• Integration of outcome assessment within multiple nursing care components.
• Identification of key nursing domains for outcome achievement.

Main Results:

• A framework for embedding outcome evaluation throughout nursing care.
• Specific nursing domains identified for maximizing patient outcome achievement.
• Improved potential for assessing the impact of nursing interventions.

Conclusions:

• Integrating outcomes into the entire nursing care process is crucial for effective evaluation.
• The proposed model guides nurses in systematically incorporating outcome assessment.
• This approach enhances the understanding and achievement of patient care goals.