| Primary Author: | Mei-Wen Wu, RN |
| Co-Principal Investigators/Collaborators: | Tsai Tzu-Chuan, RN, Ting Lee, RN, Mary Etta Mills, ScD, RN |
| Organization | Changhua Christian Hospital |
Abstract
Purpose
The purpose of the study on introduction of the mobile nursing documentation system is to investigate the influence of the document context quality and to understand the staff nurses’ comprehension regarding utilizing the mobile nursing charting system.
Background
Nursing documentation is vital for patient care. Accordingly, healthcare facilities have made greats efforts to establish a standardized mobile nursing documentation system to ensure patient care quality.
Materials & Methods
The study takes the comparison on the before and after the mobile nursing documentation system instituted .There are total 870 staff nurses from 33 units in the medical center as the object. The Method is to use closed medical review tool by JCAHO（Joint Commission on Accreditation of Healthcare Organization）to exam the document context monthly in each unit.
To study the change on the nursing documentation quality after introduction of the mobile nursing documentation system established, we collected the pre- data from January to March in the year of 2011, and the post –data from May to July in 2011; on the third month after the system instituted, we used questionnaire appraisal to investigate the relation between the staff nurses’ comprehension toward the mobile nursing document system and the change of the nursing document quality.
Results
The survey result conducted by T-TEST, it showed the documentation integrity improved from 93% to 97.44% (p=0.039) after the mobile nursing documentation system established.
From the other 88% repose rate on total 709 questionnaires exam the comprehension of the nurse staff in different units using the mobile nursing document system. A significant result conducted by ANOVA (p=0.002) showed the nurse staff have different levels of comprehension on the mobile nursing documentation system in different units.At last, there is no direct relation between the score of the comprehension on the documentation and the documentation quality according to the Regression analysis(p=0.547).
Conclusion
The study showed that implementing a standardized documentation system can have an impact on the quality of nursing documentation. For a successful system implementation, the interface design should be interactive and should be designed with equal emphasis on meeting user requirements and fulfilling clinical documentation needs.
Bibliography
The mobile nursing documentation system nursing documentation quality
© Improvement Science Research Network, 2012
The ISRN published this as received and with permission from the author(s).