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Evaluation of online documentation

C M Prophet¹, M E Krall, G K Budreau

¹Department of Nursing and Patient Care Services, University of Iowa Hospitals and Clinics, Iowa City 52242-1009, USA.

Proceedings. AMIA Symposium

|February 3, 1999

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The University of Iowa Hospitals and Clinics implemented an automated nursing information system, improving user perceptions and documentation completeness. The system enhanced compliance without increasing time spent on documentation.

Area of Science:

Health Informatics
Nursing Information Systems
Clinical Documentation Improvement

Background:

The University of Iowa Hospitals and Clinics (UIHC) introduced an in-house developed online documentation system, the Information Network for Online Retrieval & Medical Management Nursing Information System (INFORMM NIS), between 1994 and 1996.
The INFORMM NIS aimed to streamline patient care order documentation through features like automated task lists and computer-generated forms.

Purpose of the Study:

To evaluate the impact of the automated INFORMM NIS on user perceptions.
To assess changes in documentation compliance, completeness, time, and location following system implementation.

Main Methods:

A mixed-methods approach was employed, collecting data before and after the system's implementation.
Data collection involved staff surveys to gauge user perceptions and objective measures of documentation quality and efficiency.

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Main Results:

User perceptions of the system were more positive post-implementation.
Documentation compliance and completeness significantly increased.
The time required for documentation either decreased or remained unchanged.

Conclusions:

The implementation of the INFORMM NIS at UIHC successfully improved user satisfaction and documentation practices.
Automated nursing information systems can enhance efficiency and quality in clinical documentation without negatively impacting staff time.