A closer look at nursing documentation on paper forms: preparation for computerizing a nursing documentation system.

Journal Article

A small scale documentation analysis was conducted to explore the medical and surgical nursing content of the patient record at a large teaching hospital affiliated with Partners Healthcare System (PHS), in preparation for a computerized documentation system. Through this study, we identified a number of problems associated with the paper record that require resolution in the new computerized system, including elimination of documentation redundancy, areas where more structure is needed to properly capture data on nursing practice, and various design considerations to support a more complete and accurate documentation of nursing care.

Full Text

Duke Authors

Cited Authors

  • Kim, H; Dykes, PC; Thomas, D; Winfield, LA; Rocha, RA

Published Date

  • April 2011

Published In

Volume / Issue

  • 41 / 4

Start / End Page

  • 182 - 189

PubMed ID

  • 20846646

Electronic International Standard Serial Number (EISSN)

  • 1879-0534

International Standard Serial Number (ISSN)

  • 0010-4825

Digital Object Identifier (DOI)

  • 10.1016/j.compbiomed.2010.08.006

Language

  • eng