Paper
Saturday, 22 July 2006
This presentation is part of : Creative Use of Technology
A Longitudinal Study of the Effects of a Computer-Based Documentation System on Nursing Documentation
Laurie Blatt, RN1, Renee Slade, BS, CCRN, RN1, Christine Utegg, RN, BS1, and Jeanne-Marie E. Havener, PhD, RNCS, FNP, IBCLC2. (1) Nursing, Bassett Health Care, Cooperstown, NY, USA, (2) Department of Nursing, Hartwick College, Oneonta, NY, USA
Learning Objective #1: describe how a computer based documentation system effects the quality and completeness of nursing documentation in an acute care setting.
Learning Objective #2: examine the differences in nursing documentation over time and between groups of nurses working in a surgical versus a medical acute patient setting.
     The IOM’s investigation of problems in the health care delivery system of the 1990s encouraged efforts to improve quality through major and systematic changes in the organization and delivery of health services (Naylor, 2003, p. 380). Among the recommendations cited by the Committee on Quality in Health Care in America (IOM, 1999), was the need for computer-based documentation systems to improve the efficiency and quality of health care. Based on this healthcare organizations have introduced computer-based nursing documentation systems, however, little is known about how these systems alter nursing documentation. Further, the few studies that do exist demonstrate conflicting findings. Thus, this longitudinal study aimed to better understand how introduction of a computerized documentation system altered the quality and completeness of nursing documentation in an acute care setting.      Using a non-experimental, pre-test, post-test design with within and between group comparisons, documentation of key aspects of nursing care was examined prior to and following (1 month, 3 month, 6 month, and 1 year) implementation of a computer-based nursing documentation system. At each study interval a random sample of charts of patients diagnosed with one of the top five DRGs were examined. Findings indicated that nursing documentation progressivelyand significantly improved in a number of areas.  Further, nurses on the surgical unit consistently had greater improvements than their medical nursing counterparts. This suggests that while computer-based systems of documentation can significantly improve the efficiency and quality of nursing documentation, the systems may be better suited to some care delivery settings or groups. Findings from this study will contribute to a greater understanding of the costs versus benefits of computer-based documentation systems.

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