Computerized clinical documentation system in the pediatric intensive care unit

Abstract

BackgroundTo determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity.MethodsBefore and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design.ResultsWith the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable.ConclusionsWhen compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs.

Interventions to reduce medication errors in neonatal care: a systematic review

“…Online parenteral nutrition calculator [23][24][25][26][27][28][29][30] IV administration technology (n = 4) Auomated infusion devices [19][20][21][22] Barcoding (n = 3) Barcode medication administration system [31][32][33] Organizational (n = 16) Guidelines, policies, and procedures (n = 9)…”

Automatic generation of natural language nursing shift summaries in neonatal intensive care: BT-Nurse

“…These systems are based on populating forms and templates using data extracted from an electronic patient record -they do not use NLG technology to summarise the data in the patient record. Menke et al [10] found that the use of such a system in a paediatric ICU increased the quality and accuracy of documents; however they did not report any significant differences in error rates or patient outcomes. Strople and Ottani [11] made a good case for the desirability of using computers to at least partially automate the shift handover process, but did not describe or evaluate an actual system.…”

Implementation Differences of Hospital Information System (HIS) in Malaysian Public Hospitals

“…Up-to-date and accurate [12], [23] Fundamental problems such as lack of computer skills, complex tasks, complex functions [6]; [10]; [30] [37]; [47]; [48] Decrease medical errors [24]; [25], [26], [27]; [28]; [29]; [30]; [31]; [32]; [33]; [34]; [35]; [36] Ethical issues such as certification, security, privacy and confidentiality [26]; [41]; [48] …”