[Nursing records: conventional versus computerized. Critical care unit].

Area of Science:

• Nursing Informatics
• Health Information Systems
• Clinical Documentation

Background:

• Electronic clinical data systems are increasingly integrated into daily nursing workflows in hospital units.
• A specific computer program was developed for a Critical Care Unit between 2001 and 2002.
• The study addresses the transition from traditional pen-and-paper records to computerized systems.

Purpose of the Study:

• To evaluate nursing staff perceptions of computerized clinical records compared to traditional paper-based methods.
• To assess the impact of electronic health records on nursing workflow and patient care.

Main Methods:

• A survey was distributed to nursing staff in a Critical Care Unit.
• Data collection achieved a 90.5% response rate from the unit's staff.
• Qualitative and quantitative feedback on system usability and effectiveness was gathered.

Main Results:

• The majority of the nursing staff preferred the computerized record system over the pen-and-paper method.
• Electronic records were perceived as more complete, facilitating better work organization and reliability.
• Staff reported increased time spent on documentation but paradoxically more time available for direct patient care.

Conclusions:

• The implementation of a computerized clinical record system has positively impacted nursing perception and workflow.
• Despite a perceived increase in documentation time, the electronic system is viewed as an improvement for patient care delivery.
• The computerized system is considered an effective and reliable work tool for nursing staff.