J Korean Acad Fundam Nurs.  2006 Apr;13(1):24-32.

A Comparison of Efficiency between Computerized Nursing Records and the Paper-based Nursing Records: focus on patients with a stroke

• Sung YH
• Cho MS
• Jang MR
• Choi BY

Abstract

PURPOSE: This study was a comparative review of the computerized nursing records and paper-based nursing records to examine effects of a nursing process documentation system focusing on patients who have had stroke. METHOD: First, the researchers collected all the foci from the computerized records and the paper-based records. They selected ten nursing foci, used frequently in both groups and analyzed the number of foci per patient, appropriateness of foci, the number of nursing activities per nursing focus and whether outcomes were described or not in the nursing record.
RESULTS
There was fewer errors in nursing diagnosis selection, and a larger number of activities in the records than the paper based ones. Also, there was a better description of the nursing outcomes in the computerized records.
CONCLUSION
This study suggests that the computerized nursing records is significantly effective in increasing accuracy of the nursing care plan and quality of the nursing record.

Keyword

Nursing records

MeSH Terms

Humans
Nursing Diagnosis
Nursing Process
Nursing Records*
Nursing*
Patient Care Planning
Stroke*