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

Full Abstract

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.

Author information

Author/s: Mahler, Cornelia (C); Ammenwerth, Elske (E); Wagner, Andreas (A); Tautz, Angelika (A); Happek, Torsten (T); Hoppe, Bettina (B); Eichstädter, Ronald (R);

Affiliation: University Hospital Heidelberg, Heidelberg, Germany. cornelia.mahler(-atsign-)med.uni-heidelberg.de

Journal and publication information

Publication Type: Journal Article

Journal: Journal of medical systems (J Med Syst), published in United States. (Language: eng)

Reference: 2007-Aug; vol 31 (issue 4) : pp 274-82

Dates: Created 2007/08/09; Completed 2007/08/28;

PMID: 17685151, status: MEDLINE (last retrieved date: 2/18/2009)

Sourced from the National Library of Medicine. Abstract text and other information may be subject to copyright.

External Links for this article
(including full text providers, if available):

Click Electronic Full-text Provider Links to see options for finding the electronic full text links to this article. Note there may be a subscription or fee required for access to the full text. See our FAQ for information on finding FREE full text articles.

This article may also be located in paper journal collections available in many libraries. Use the Journal and Publication Information above to find the full article.