Computer based nursing documentation means to achieve the goal

• HIT Description: Electronic ICU nurse charting. More info...
  
• Purpose of Study: Describe an implementation of an electronic nurse charting system in the intensive care unit of a German hospital information system.
  
• Years of study: Published in 1998.
  
• Study Design: Descriptive.
  
• Outcomes: Comparison of electronic charting with paper charting. Average utilization of the system.
  

• Settings: An academic university hospital in Germany.
• Intervention: A computer-based nursing documentation system to record the therapeutic intervention scoring system (TISS).
• Evaluation Method: Comparison of TISS scores using the computer to those obtained with a paper recording system and utilization of the system.
• HIT System: At the university hospital there are 1200 clinical workstations in almost every ward, outpatient clinic and doctor's office, throughout the hospital campus. These are connected through a modern network. Clinical patient data are maintained in an in-house developed system called WING, running on a TANDEM Himalaya mainframe that can be accessed either through IBM compatible PCs via terminal emulation or via Macintosh Power PCs using client-server technology in a graphical user interface.
• Extrinsic Factors in valuing cost and benefits: Changes in legislation in Germany regarding hospital financing required substantially greater documentation of the intensity of care delivered in order to justify intensive care unit reimbursement. Accurate collection of TISS data on each patient was judged to be an important means for the hospital to provide such documentation.
• Cost of Implementation: The authors report that no specific ICU software has been used nor have bedside workstations been installed in all wards and therefore, Òwas comparatively low expenses we have achieved on average 14 nursing and medical interventions are being documented for each patient, each day,Ó and that the system was Òimplemented without major financial or manpower investmentsÓ.
• Quality of Care and Patient Safety Outcome: During a one month period, both computerized and paper forms were used to record TISS data. The authors report that up to 10% of the paper forms contained false TISS scores due to mathematical errors, putting 41% of patients into a false TISS category. The authors stated that the use of the electronic system provided more complete documentation due to the reminder for missing entries and also a Òremarkable improvementÓ in data quality.