A randomized evaluation of a computer-based nursing documentation system

• HIT Description: A nursing documentation system More info...
  
• Purpose of Study: To assess the effect of computer based nursing documentation system on nursing care.
  
• Years of study: 1998-1999
  
• Study Design: A randomized control trial
  
• Outcomes: Nursing time utilization, quality of nursing documentation, and user acceptance.
  

• Settings: Inpatient psychiatry service at a university hospital in Germany.
• Intervention: Implementation of a computerized nursing documentation system compared to a structured paper based system.
• Evaluation Method: Records for 60 inpatients were randomized to either the computer or paper system. Data was collected over a two month period. 11 nurses were involved.
• HIT System: A computerized nursing documentation system that supported patient problem lists, nursing care aims, planning nursing care/ interventions, facilitated execution of nursing care, and facilitated evaluation of nursing care.
• Implementation: Nurses were said to have prior experience with computers for entering some order, writing discharge reports and administrative tasks. No further descriptions were given.
• Clinical Outcomes: Time required for care planning was decreased using the computer system (16 min vs 43). Many nurses did not complete care planning through paper due to difficulty in completing the function on paper per authors report. Documentation of tasks and report writing each took longer using the computer (documentation 4.8 min vs. 2.0 min and reports 6.6 min vs. 4.7 min).
• Benefits: Measures of documentation quality all showed moderate to large improvements with the computer system. 8 of the 11 nurses Òpartly agreedÓ that the system was user friendly and 3 of the 11 Òpartly disagreedÓ that the system was user friendly.