Prerequisites. of computer-based. nursing documentation. C. Mahler
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1 of computer-based nursing documentation C. Mahler E. Ammenwerth, R. Eichstädter, R. Haux, B. Hoppe, M. Kandert, A. Kutscha, G. Luther, U. Pohl Dept. of Dermatology, Paediatrics, Psychiatry Dept. of Medical Informatics
2 in introducing documentation systems in general Hlimited acceptance of the nursing process Hdifficulties in formulating Hbad project management specific to computers Hcomputer anxious users Hinsuff. standardisation of nursing terminology Hinsuff. functionality of software Hinsuff. integration into hospital environment Hfear of less individual care
3 1. standardisation issues 2. acceptance issues 3. technical issues 4. organisational issues
4 standardisation issues Standardisation of nursing terminology using predefined nursing care plans Advantages H easy and efficient care-planing H reduction of documentation efforts H reduction of terminological difficulties H comparability and transparency of nursing care H quality assessment H support in training new staff members
5 structure of care plans predefined nursing care plans nursing items (problems, aims, tasks,) nursing terminology ( for.ex. ICNP)
6 ICNP 1) 2) standardisation of nursing terminology indexing of nursing documentation predefined nursing care plans nursing items (problems, aims, tasks,) nursing terminology ( for.ex. ICNP)
7 Predefined nursing care plan in PIK
8 Dokumentation of nursing activities
9 creation of care plans Number of predefined nursing items and predefined nursing care plans in the three departments before and after the introduction of a computer-based nursing documentation system. Department Dept. of Dermatology Dept. of Pediatrics Dept. of Psychiatry Date Oct. 00 Dec. 00 Oct. 00 Dec. 00 Sept. 98 Dec. 00 Predefined resources Predefined problems Predefined aims Predefined tasks Predefined care plans
10 acceptance issues acceptance of the nursing process 4,0 Gesamteinschätzung PIK (Zeitpunkt 2) 3,5 3,0 2,5 2,0 1,5 1,0 1,0 1,5 2,0 2,5 3,0 3,5 ID Station Nei H11 Ber 4,0 Mittelwert Akzeptanz Pflegeprozess - Zeitpunkt 1 no correlation!
11 acceptance issues acceptance of computers in nursing 4,0 3,5 Gesamteinschätzung PIK (Zeitpunkt 2) 3,0 2,5 2,0 1,5 1,0 1,0 1,5 2,0 2,5 3,0 3,5 ID Station Nei H11 Ber 4,0 Mittelwert Akzeptanz Computer i.d. Pflege - Zeitpunkt 1 correlation positive (p<0,05)
12 technical issues: functionality of software basic requirements Hmaintenance of predefined care plans/catalogues Hnursing anamnesis Hcare planning, documentation and evaluation Hnursing report writing (free text) Hflexible user management support the individual needs of every ward Hnursing theory, forms, predefined care plans support co-operation between health care professionals
13 technical issues integration into hospital environment: Hinterfaces to patient management and billing system Hsufficient hardware Hintegration into electronic patient record workflow integration: Hstationary or mobile computers HSoftware should support typical workflow of all health professionals
14 organisational issues support by nursing management interdisciplinary project team clear introduction strategy: Hselection of motivated pilot wards Hsufficient training Hinstallation of hardware Hintegration in nursing workflow Hinformation of other professional groups definition of support levels: Htechnical support Huser support Hterminological support
15 consideration of many prerequisites interdisciplinarity of project team is very important standardisation issues regarding nursing terminology are just beginning in Germany chance of successfully introducing the nursing process Can classification systems (ICNP) be integrated into daily work routine?
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