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The impact of computerized documentation on nurses' use of time
M K Pabst1, J C Scherubel, A F Minnick
1Nursing Services Research & Support, Chicago, IL 60612. mpabst@cnis.rpslmc.edu
Abstract:
With increased consideration being given to technological supports as a way to increase productivity, much attention is being paid to automated documentation systems. The purpose of this study was to determine (A) if bedside documentation technology decreased the time nurses spent in documentation activities and (B) if time of day, location, and quality of documentation differed between automated and nonautomated units. Nurses on the automated unit were able to decrease time spent in documentation activities and they were able to increase time spent in direct patient care. Some increase in standby time also was reported. Nurses were not able to increase patient loads as a result of this technology alone. Managers must consider ways to maximize use of time saved as a result of technology. Nurses on the automated unit were able to update care plans more easily and, along with other professionals, reported both positive and negative aspects of the printed output.
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Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Methods of Documentation II: POMR
Methods of Documentation III: PIE
Methods of Documentation IV: Focus Charting
It typically involves three columns for recording information:
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security: