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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This work was funded by the Italian Centre of Excellence for Nursing Scholarship, Rome, Italy.
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D’Agostino, F. et al. (2019). Impact of an Electronic Nursing Documentation System on the Nursing Process Accuracy. In: Di Mascio, T., et al. Methodologies and Intelligent Systems for Technology Enhanced Learning, 8th International Conference. MIS4TEL 2018. Advances in Intelligent Systems and Computing, vol 804. Springer, Cham. https://doi.org/10.1007/978-3-319-98872-6_29
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DOI: https://doi.org/10.1007/978-3-319-98872-6_29
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