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Computerised versus handwritten records.

Mandi Whyte1

  • 1Royal Liverpool Children's Hospital, Alder Hey.

Paediatric Nursing
|September 24, 2005
PubMed
Summary
This summary is machine-generated.

Inadequate nursing record keeping in paediatric intensive care units (PICU) and high dependency units (HDU) was identified. Computerised systems show potential to improve upon handwritten records, necessitating regular staff training.

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Area of Science:

  • Healthcare quality improvement
  • Nursing informatics
  • Patient safety

Background:

  • The Victoria Climbié case underscored critical failures in record-keeping.
  • A review identified significant concerns regarding nursing record quality in a UK paediatric intensive care unit (PICU).
  • This led to an audit comparing handwritten records in the PICU with computerised records in the high dependency unit (HDU).

Purpose of the Study:

  • To audit and compare the standard of nursing record keeping between handwritten (PICU) and computerised (HDU) systems.
  • To identify deficiencies in current record-keeping practices within a children's hospital setting.
  • To inform improvements in nursing documentation to enhance patient safety.

Main Methods:

  • An audit was conducted comparing nursing records from PICU (handwritten) and HDU (computerised).

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  • Evaluation focused on the quality, completeness, and accuracy of documentation in both units.
  • Data from the audit were analyzed to identify common errors and omissions.

    • Main Results:

    • Record keeping in both the PICU and HDU was found to be sub-standard across multiple aspects.
    • Both handwritten and computerised systems exhibited faults.
    • Computerised record keeping demonstrated a potential to mitigate some errors and omissions observed in handwritten notes.

    Conclusions:

    • Nursing record keeping requires significant improvement in both handwritten and computerised formats.
    • Computerised systems offer advantages in potentially reducing documentation errors.
    • Mandatory, regular training for nurses on record-keeping knowledge and skills is essential and has been implemented.