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Related Experiment Videos

Evaluating the impact of computerized clinical documentation.

Kathy Smith1, Vivienne Smith, Mary Krugman

  • 1University of Colorado Hospital, Denver, CO 80262, USA. Kathy.smith@uch.edu

Computers, Informatics, Nursing : CIN
|May 19, 2005
PubMed
Summary

Implementing a computerized nursing system showed mixed results. While documentation completeness improved, staff attitudes toward computers became less positive, and charting time remained unchanged.

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Area of Science:

  • Nursing Informatics
  • Health Information Systems

Background:

  • Computerized systems are increasingly used in healthcare for documentation.
  • Standardized languages like Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) provide a framework for electronic health records.

Purpose of the Study:

  • To evaluate the impact of a computerized care planning and documentation system on nursing staff.
  • To assess changes in staff attitudes, documentation time, and charting completeness.

Main Methods:

  • A study was conducted at a western teaching hospital before and after implementing a computerized system.
  • Data were collected through staff surveys, direct observation of charting time, and chart audits.

Main Results:

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  • Staff attitudes toward computerization became less positive post-implementation.
  • The time required for documentation remained unchanged.
  • There was a significant improvement in the comprehensiveness of nursing charting entries.

    • Conclusions:

    • Computerized nursing documentation systems can enhance the completeness of patient care records.
    • Addressing staff attitudes and workflow integration is crucial for successful technology adoption in nursing.