Effects of a computer-based nursing documentation system on the quality of nursing documentation.

摘要

Nursing documentation is an important part of clinical documentation. However, documentation of the nursing process is frequently lacking quality. There are high expectations that computer support in nursing documentation will help improve documentation quality. This study aimed to examine whether the introduction of a computer based nursing documentation system can improve documentation quality. A prospective intervention study was conducted on 4 wards of the University Medical Center Heidelberg over a period of 18 months. Two wards in the Psychiatric University Medical Center Heidelberg were involved in the research study, as well as a dermatological and a pediatric ward. The results of the study show a significant improvement of documentation quantity and quality on three of the four wards. Positive aspects include completeness of documentation on the nursing process, formal aspects and subjective quality improvement by the nurses. Negative aspects were mainly associated with the contents of the care plans.