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Impact of an Electronic Nursing Documentation System on the Nursing Process Accuracy

Authors:
  • Saint Camillus International University of Health Sciences
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Abstract

While the nursing process provides a framework for documenting nursing practice and delivering patient-focused care, nurses often have difficulty applying the nursing process in clinical practice. Fortunately, electronic nursing documentation using clinical decision support systems (END-CDSS) can improve the accuracy of recorded nursing process. To date, however, no study has evaluated nursing documentation accuracy over time following END-CDSS implementation. Accordingly, the aim of this study was to evaluate if the Professional Assessment Instrument (PAI) END-CDSS improved the accuracy of nursing documentation in an Italian hospital cardiology inpatient unit. A quasi-experimental longitudinal design was conducted. A random sample of 120 nursing documentations was collected and evaluated using the D-Catch instrument. A significant improvement (p < .001) in nursing documentation accuracy scores was shown after PAI implementation. These results suggest that an END-CDSS can support nurses in the nursing process by improving their clinical reasoning skills.

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... Furthermore, it improves communication, not only between healthcare providers, but also between nurses themselves (Rutherford, 2008). In addition, the accuracy of nursing documentation is important for patient safety and care (D'Agostino et al., 2019). ...
... electronic health records, linkages, nurses, nursing, nursing diagnosis, nursing interventions, nursing outcomes, nursing records, pre-hospital emergency care, standardized nursing terminology . Its use improves patient outcomes and documentation accuracy (D'Agostino et al., 2019). The use of nursing diagnoses proposed by NANDA-I is recommended to identify the human responses that nurses address (Herdman et al., 2021). ...
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