Learning Objective #1: Identify ways in which a computer-based documentation system can improve the quality of patient care

Learning Objective #2: Name three ways that a computer-based documentation system can enhance nursing documentation of quality indicators

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During the late 1990s, roundtable discussions on the issue of quality in healthcare were convened by the Institute of Medicine. This group found widespread problems in the healthcare delivery system that resulted in actual or potential serious harm to patients. The group concluded that "efforts to improve quality would require a major and systematic overhaul in the organization and delivery of health services and in the education of healthcare professionals (Naylor, 2003, p.380). Among the '10 rules' for healthcare redesign cited by the Committee on Quality Health Care in America (IOM, 1999) is the need for computer-based documentation systems to improve the efficiency and quality of health care. Using retrospective chart audits this study sought to understand differences in the quality of nursing documentation related to key quality indicators prior to and following (1 month, 3 months, and 6 months) the implementation of a computer-based documentation system. Results indicate that computer-based systems of documentation can significantly improve the efficiency and quality of nursing documentation.