Impact of an electronic nursing documentation system on the nursing process accuracy

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.

Nursing documentation accuracy, Nursing process, Electronic nursing documentation, Clinical decision support system,  Longitudinal design