Computerization of a Nursing Chart According to the Nursing Process.
María B. Schachner, Zulma A González, Janine Sommer, Francisco J. Recondo, Fernando D. Gassino, Daniel Roberto Luna, Sonia Benítez
Abstract
María B. Schachner, Zulma A González, Janine Sommer, Francisco J. Recondo, Fernando D. Gassino, Daniel Roberto Luna, Sonia Benítez
Abstract
The benefits associated with the computerization of clinical records are known since a long time ago. Documentation evolution from paper to electronic format aims to always improve communication, reduce errors and facilitate continuity of care. Ideally when improvements to nursing records are contemplated, they should consider the nurses needs, new functionality workflow impacts and correspondence with representation models of standardized data that are specific to their domains practices. The aim of this study was to describe the development and implementation of computerized nursing record at Hospital Italiano de Buenos Aires.
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The benefits associated with the computerization of clinical records are known since a long time ago. Documentation evolution from paper to electronic format aims to always improve communication, reduce errors and facilitate continuity of care. Ideally when improvements to nursing records are contemplated, they should consider the nurses needs, new functionality workflow impacts and correspondence with representation models of standardized data that are specific to their domains practices. The aim of this study was to describe the development and implementation of computerized nursing record at Hospital Italiano de Buenos Aires.
Key concepts: Workflow, Documentation, Nursing Minimum Data Set, Chart, Nursing records, Nursing process, Nursing documentation, Nursing