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Computerized clinical documentation system in the pediatric intensive care unit.

J A Menke1, C W Broner, D Y Campbell

  • 1Department of Pediatrics, Children's Hospital and The Ohio State University, Columbus, OH, USA. menkej@pediatrics.ohio-state.edu

BMC Medical Informatics and Decision Making
|October 18, 2001
PubMed
Summary
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A computerized clinical documentation system (CDS) improved patient record quality and accessibility without increasing nursing time. The CDS also enhanced shift-to-shift reporting and management capabilities.

Area of Science:

  • Health Informatics
  • Clinical Documentation Systems
  • Nursing Informatics

Background:

  • Assessing the impact of Computerized Clinical Documentation Systems (CDS) on nursing workflow and patient care quality.
  • Evaluating the potential of CDS to reduce medication errors and improve clinical decision-making.
  • Investigating the effect of CDS on documentation completeness and inter-shift nursing communication.

Purpose of the Study:

  • To evaluate if a CDS decreases charting time and increases patient care time.
  • To determine if a CDS reduces medication errors and enhances clinical decision-making.
  • To assess the impact of CDS on documentation quality and nursing shift continuity.

Main Methods:

  • A modified one-group pretest-posttest design was employed.

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  • Time studies of nursing care and medication delivery were conducted before and after CDS implementation.
  • Documentation completeness and clinician perceptions of shift reporting were evaluated via surveys.

    • Main Results:

    • The CDS resulted in improved documentation legibility, completeness, accessibility, and accuracy.
    • No significant change was observed in time spent on direct patient care or charting by nursing staff.
    • Incidental findings included improved management functions, JCAHO compliance, and reduced audit costs.

    Conclusions:

    • The CDS provides a more legible, complete, and accessible patient record compared to paper charts, without negatively impacting nursing time.
    • Implementation of the CDS improved shift-to-shift nursing reporting and overall management capabilities.
    • The system demonstrated benefits in data entry, reimbursement, and cost reduction.