DIFFERENCE IN NURSING DOCUMENTATION
BEFORE AND AFTER COMPUTERIZATION:
A PILOT STUDY
Sandra Boldreghini, MSN, RN, CS
June H. Larrabee, PhD, RN
While revolutionary changes are reshaping the health care arena in the USA, nurses are candidly pursuing empirical evidence of their contributions to health care outcomes. This pilot study investigated documentation comprehensiveness of nursing interventions or nurse-perceived quality (quality) and nurse goal achievement (beneficence), as well as the relationship between quality and beneficence before and after implementing a nursing information system (NIS). Data were obtained from records of 20 patients pre- and 20 patients postimplementation. Results indicated that computerized documentation did not improve either nurse-perceived quality or nurse goal achievement. Nor was there a relationship between quality and beneficence. Implications include revising the NIS to facilitate nurse goal achievement documentation, reeducating nurses to individualize care plans, and periodically assessing quality and improving the focus on documentation comprehensiveness. Replication of this study with a larger sample is needed to confirm the findings.
Key Words: Evaluation of Computerization, Quality, Beneficence, Nursing Interventions, Nursing Outcomes.