Using computers to speed up the nursing process

Nursing, Aug 2002

A COMPUTER INFORMATION system can either stand alone or be part of a larger system the whole facility uses. A nursing information system (NIS) can increase efficiency and accuracy in all phases of the nursing process-assessment, nursing diagnosis, planning, implementing, and evaluating. It can help you meet standards of nursing practice and documentation. In addition, an NIS can help you spend more time meeting patients' needs.

Consider the following uses of computers in the nursing process.

Assessment

Use the computer terminal to record admission information. As you collect data, enter further information as prompted by the computer's software program. Enter data about the patient's health status, history, chief complaint, and other assessments.

Some software programs prompt you to ask specific questions, then offer pathways to gather further information. In some systems, if you enter a value that's outside the usual acceptable range, the computer will flag the entry so you can fix it.

Nursing diagnosis

Most current programs list standard diagnoses with associated signs and symptoms as references. After you use your clinical judgment to determine a nursing diagnosis for each patient, you can rapidly get information related to that diagnosis.

For example, the computer can generate a list of possible diagnoses for a patient with certain signs and symptoms or it may enable you to retrieve and review a patient's records according to the nursing diagnosis.

Planning

To help you begin writing a plan of care, newer computer programs display recommended interventions for the selected diagnoses and expected outcomes. Computers also can track outcomes for large patient populations.

Implementing

Use the computer to record interventions and patient information, such as transfer and discharge instructions, and to communicate this information to other departments.

Computer-generated progress notes automatically sort and print out patient data-such as medication administration, treatments, and vital signs-making documentation more efficient and accurate.

Evaluating

You can use computers to compare large amounts of patient data, help identify outcomes patients are likely to achieve based on individual problems and needs, and estimate the time frame for reaching outcome goals.

During evaluation, use the computer to record and store observations, patients' responses to nursing interventions, and your own evaluation statements. You also may use information from other health care team members to determine future actions and discharge planning. If a desired patient outcome hasn't been achieved, record new interventions taken to ensure desired outcomes. Then reevaluate them.

Source: Charting Made Incredibly Easy!, 2nd edition, Lippincott Williams & Wilkins, 2002.