Nursing process documentation systems in clinical routine

International Journal of Medical Informatics 64 (2001) 187–200

Nursing process documentation systems in clinicalroutine—prerequisites and experiences

Elske Ammenwerth a,1*, Ulrike Kutscha b, Ansgar Kutscha c,Cornelia Mahler b, Ronald Eichstadter d, Reinhold Haux a

a Department of Medical Informatics, Institute for Medical Biometry and Informatics, Uni�ersity Medical Center,Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

b Department of Dermatology, Uni�ersity Medical Center, 69120 Heidelberg, Germanyc Department of Pediatrics, Uni�ersity Medical Center, 69120 Heidelberg, Germany

d Department of Psychiatry, Uni�ersity Medical Center, 69120 Heidelberg, Germany

Abstract

Documentation of the nursing process is an important, but often neglected part of clinical documentation.Paper-based systems have been introduced to support nursing process documentation. Frequently, however, prob-lems, such as low quality and high writing efforts, are reported. However, it is still unclear if computer-baseddocumentation systems can reduce these problems. At the Heidelberg University Medical Center, computer-basednursing process documentation projects began in 1998. A computer-based nursing documentation system has nowbeen successfully introduced on four wards of three different departments, supporting all six phases of the nursingprocess. The introduction of the new documentation system was accompanied by systematic evaluations ofprerequisites and consequences. In this paper, we present preliminary results of this evaluation, focusing onprerequisites of computer-based nursing process documentation. We will discuss in detail the creation and use ofpredefined nursing care plans as one important prerequisite for computer-based nursing documentation. We will alsofocus on acceptance issues and on organizational and technical issues. © 2001 Elsevier Science Ireland Ltd. All rightsreserved.

Keywords: Nursing documentation; Nursing process; Evaluation study; Acceptance; Nursing care plan; ICNP

www.elsevier.com/locate/ijmedinf

1. Introduction

Nursing documentation is one importantpart of clinical documentation. A thoroughnursing documentation is a precondition forgood patient care and for efficient communi-cation and cooperation within the healthcareprofessional team [1,2].

* Corresponding author. Present address: University forHealth Informatics and Technology Tyrol Innrain 98, 6020Innsbruck, Austria. Tel.: +43-512-58-67-34809; fax: +43-512-58-67-34850.

E-mail address: [email protected] (E. Ammen-werth).

1 www.mit-hit.at

1386-5056/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved.

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E. Ammenwerth et al. / International Journal of Medical Informatics 64 (2001) 187–200188

Nursing care is usually oriented toward theso-called nursing process. The nursing pro-cess provides a systematic methodology fornursing practice [3]. It consists of six phases:(1) assessment of relevant information; (2)definition of patient problems and resources;(3) derivation of nursing aims; (4) planning ofnursing tasks; (5) execution and documenta-tion of these tasks; (6) evaluation of nursingcare and possibly redefinition of the care plan[4].

Paper-based systems have been introducedto support nursing process documentation.Frequently, however, high documentation ef-forts, low quality and limited acceptance ofthe nursing process [2,5–7] are reported.

There have been many attempts to supportthe nursing process using computer-baseddocumentation systems. The aim is to reducedocumentation efforts, to increase documen-tation quality and to allow reuse of data fornursing management and nursing research.But despite high investments, problems asso-ciated with computer-based documentationsystems are reported, for example, an insuffi-cient reflection of the complexity of the nurs-ing process, a lack of a standardized nursingterminology, computer-anxious users, fear ofless individual care and too much control,high implementation and operation costs,and unclear benefits [8–14].

Yet, the actual effects of computer-basednursing documentation systems have hardlybeen systematically evaluated. Studies evalu-ating some effects of computer-based nursinginformation systems exist [13,15–22], how-ever only few concentrated on some phases ofcomputer-based nursing process documenta-tion (mostly on care planning) [2,5,23–25].

Overall, it seems unclear which prerequi-sites and consequences these systems have.Consequently, the project ‘computer-basednursing process documentation’ was initiatedat the Heidelberg University Medical Center

in 1998. A computer-based nursing processdocumentation system (‘PIK’) was selectedand successfully introduced on four pilotwards in three departments (Department ofPsychiatry: two wards; Department of Der-matology and Department of Pediatrics: oneward each). The introduction was followedby a long-term, systematic evaluation studyof prerequisites and consequences of the com-puter-based documentation system.

Some results of our randomized evaluationstudy on the first pilot ward have alreadybeen published [26,27]. The evaluation of theother three wards is still under way.

The aim of this paper is to present firstresults concerning prerequisites of computer-based nursing process documentation sys-tems. Several general prerequisites, such asgeneral motivation and involvement of theusers, computer knowledge and attitudes,and general organizational issues, are wellknown [28–31] and are not specific to thearea of the nursing process. In this paper, wewill instead focus on specific prerequisites fornursing process documentation. We will dis-cuss the creation and use of predefined nurs-ing care plans as one important prerequisitefor computer-based nursing documentation.We will also focus on acceptance issues andon organizational and technical issues.

2. Functionality of computer-based nursingprocess documentation systems

In this chapter, we present the typical func-tionality of a computer-based nursing processdocumentation system, based on the exampleof the documentation system PIK (‘Pflegein-formations-und Kommunikationssystem’—‘Nursing information and communicationsystem’) used in Heidelberg. The aim of thesedocumentation systems is to support all sixphases of the nursing process. A detailed

E. Ammenwerth et al. / International Journal of Medical Informatics 64 (2001) 187–200 189

description of the nursing documentation sys-tem PIK can be found in [32].

Nursing anamnesis is usually supported bythe ability to define and use individual forms(for example, for social anamnesis), contain-ing structured and unstructured information.

Based on the information gathered in theanamnesis, a nursing care plan for an individ-ual patient can then be created. To supportthis, typical nursing problems, aims and taskscan be predefined and selected during cre-ation of the care plan. Typical combinationsof problems, aims and tasks can even becombined in predefined nursing care plans.

Later, during care planning, these pre-defined items and standards can be selectedand adapted to the patients individual needsby adding or removing certain items. Thismakes care planning much easier and moreefficient than conventionally possible.

Fig. 1 presents a typical computer-basedcare plan for a patient: (recent and potential)problems, aims and planned tasks are pre-sented in different columns.

Based on this care plan, nursing tasks areexecuted and documented, usually using atime axis within the documentation form.The system allows the documentation ofplanned tasks or other tasks along with infor-mation of special observations oroccurrences.

In Fig. 2, an example for the documenta-tion of planned tasks is presented.

In addition, nursing aims can be planned,checked and documented. The procedure isnearly identical to that of task documenta-tion. Finally, nursing reports can be written,usually containing free text. Individual nurs-ing reports may be highlighted for otherhealth care professionals.

The functionality described above coversthe six phases of the nursing care process.Usually, in addition, computer-based docu-mentation systems offer functions for wardmanagement (for example, patient manage-ment and use of general forms), for manage-ment of the predefined care plans, and for theuse of nursing knowledge (such as nursingstandards).

Fig. 1. A typical computer-based care plan for a patient. Two predefined care plans have been used. The columns 1–5contain resources, recent problems, potential problems, aims and planned tasks. All screenshots are taken from thedocumentation system PIK.


Fig. 2. Typical documentation of planned or other tasks in a computer-based documentation system. The first columnpresents the list of planned tasks. The time axis is scalable (minutes, hours, days or weeks).

3. Prerequisite: standardization issues

An essential precondition for the introduc-tion of computer-based nursing process docu-mentation is the predefinition of items(nursing problems, aims and tasks) and ofpredefined nursing care plans (as a combina-tion of problems, aims and tasks). All docu-mentation can then be done based on thosecatalogues.

The use of predefined care plans is seen tohave several advantages [5,8,33]: First of all,using predefined care plans, makes care plan-ning easier and more efficient, by extremelyreducing documentation efforts and termino-logical difficulties during care planning. Sec-ondly, those predefined care plans can makenursing more transparent, reproducible andcomparable. They can thus be seen as onestep towards quality management in nursing.Thirdly, predefined care plans support learn-ing and exchange of knowledge within the

nursing team. Fourthly, as documentationbecomes more complete, fewer items are for-gotten, and the question ‘what do nurses do’is easier to answer. Last of all, using pre-defined care plans supports the understand-ing and implementation of the nursing careprocess and is therefore of extreme help tonursing education. It should be mentionedthat most of these advantages are not specificto computer-based documentation, but alsoresult from conventional documentationbased on predefined care plans.

In the next paragraphs, we will discussstructure, content, creation and usage of pre-defined care plans during computer-baseddocumentation.

3.1. Structure

Predefined nursing care plans are usuallybased on items (such as problems, aims andtasks), which themselves are based on a nurs-ing terminology (Fig. 3).


Predefined care plans are mostly specific toa nursing field (for example, surgery or psy-chiatry). Nursing items may be field-depen-dent, but may also be used in more than onefield (for example, ‘decubitus’ as a nursingproblem). Nursing terminology should beuniversally valid to enable exchange, analysisand comparisons of items and care plans.

A universal nursing terminology which isjust being developed is the ICNP (Interna-tional Classification of Nursing Practice). Theaim of the ICNP is to establish a commonlanguage for describing nursing practice, todescribe nursing care, and to enable compari-son of nursing data across clinical popula-tions, settings, geographic areas and time[34–37].

When creating nursing care plans, theICNP can be used in two areas: First, it canbe seen as the nursing terminology used tobuild nursing items and predefined careplans. Second, it can be used for indexingnursing items and care plans as a basis fornursing data analysis (both for nursing re-search and management).

In 1998, we started using the alpha versionof ICNP as a basis for nursing items and careplans but quickly learned that the alpha ver-sion was not sufficient and incomplete. Sev-eral terms used in the pilot Department of

Dermatology could not be matched to ICNPterms. Nevertheless, the relevance of a com-mon nursing terminology is well known.Therefore, we are just starting a similar pro-ject, now using the recent beta-version of theICNP.

3.2. Content

The content of predefined nursing careplans can be oriented towards different aims:they may represent typical medical diagnosis(for example, HIV), or nursing diagnosis (forexample, itching), but also, they may repre-sent typical sequences of tasks (for example,tasks during patient admission, pneumoniaprophylaxis, or the monitoring of suicidepatient).

By reviewing the content, we could observea typical development on our somatic wards.We observed that the first nursing care planswere either based on medical diagnosis orwere task oriented. However, after sometime, the wards learned that certain nursingproblems reappeared in various care plans(such as itching in dermatological care plans).This motivated them to reformulate the pre-defined care plans which now are more basedon nursing diagnosis.

In contrast, the care plans used by thepsychiatric wards have been oriented towardnursing diagnosis all along. The reason maybe that nursing process documentation hasbeen established fore some years, in contrastto the somatic departments.

We learned that the wards tended to startwith rather long predefined care plans. Aftersome experience, they began splitting theminto smaller parts (for example, containingno more than 20 items).

Another observation we made was thateach department began with self-formulatednursing care plans. After several months ofworking with these plans, the pilot wards are

Fig. 3. Creation of predefined nursing care plans basedon nursing items and nursing terminology.


Table 1Number of predefined nursing items and predefined nursing care plans in the three departments before (first date) andafter (second date) introduction of a computer-based nursing documentation system

Department Department of PediatricsDepartment of Dermatology Department of Psychiatry

December 00 October 00 December 00Date September 98October 00 December 00

13 6 –Predefine 0 – 18resources

110 174 223Predefined 242 – 436problems

69 72 136Predefined 111 – 201aims

124 183 271Predefined 260 – 293tasks

Predefined 12 20 23 30 36 55care plans

The number of items for September 98 is not available.

now considering to establish ‘general’ hospi-tal-wide care plans which are to be valid forevery department. Examples are pneumoniaprophylaxis or patient mobilization, nursingactivities which are relevant in each of thepilot departments. Obviously, there are someoverlaps in care plans which can and shouldbe standardized to ease the maintenance ofthe predefined care plans.

3.3. Creation

Before the introduction of a computer-based nursing documentation system, a cer-tain amount of nursing items (problems,aims, tasks) and predefined nursing careplans must be prepared.

Table 1 presents the number of items andcare plans on our four wards during thebeginning of the projects and again in De-cember 2000. The numbers indicate that theitems and catalogues must be maintained reg-ularly, adapted and extended as the wardbecomes more and more accustomed to com-puter-based documentation.

Our experiences show that the preparationof the items and care plans take severalmonths for a department, depending on theamount of information which can be reusedfrom other wards. This effort will certainly bepartly reduced in the next years, when acommon nursing terminology (for example,ICNP) is available to cover a certain part ofthe catalogues. In addition, as more andmore departments begin developing pre-defined care plans and nursing items, thisinformation can be reused, most probablyreducing the required preparation time.

3.4. Usage

A documentation system must be well inte-grated into the clinical workflow in order tobe of use. Predefined care plans are an impor-tant issue in this context. In this paragraph,we will shortly describe how the documenta-tion system and the predefined care plans cantypically be used.

The patient admission is based on a task-oriented admission standard, using a pre-defined form for nursing anamnesis. Based


on this information, the responsible nursecreates the first care plan for the patient.After selecting adequate care plans, they areadapted to the individual needs. Mostly,items are removed (for example, problemswhich do not apply). Sometimes, items areadded (such as individual patient resources).Obviously, it is much easier to find a list ofpossible problems than to find a list of possi-ble individual resources. There are too manypossible patient resources to list them all.Thus, a nurse using a predefined care planmust be motivated to add individual patientresources, and to eliminate the problems (andaims and tasks) which do not apply.

The description shows that the use of pre-defined care plans integrate the steps 2–4 ofthe nursing process (definition of problemsand patient resources; derivation of nursingaims; planning of nursing tasks) into one careplanning step, i.e. choosing and editing a

patient-related care plan. This procedureseems to simplify care planning and improvesthe nursing attitude towards the nursingprocess.

On our four pilot wards, we observed thatthe amount of changes to the predefined careplans grew the more familiar the nurses be-came with the computer-based documenta-tion system. Fig. 4 shows some statistics forone ward.

After care planning, the execution ofplanned tasks can be scheduled, if necessary.After executing the tasks, they can be docu-mented and information and observationsmay be added. This documentation is carriedout a multiple number of times during eachshift.

The evaluation of planned aims is alsoscheduled. When the planned dates arereached, the accomplishments of the aims arechecked. Depending on the results, the care

Fig. 4. Number of predefined care plans and amount of modifications of the care plans of 58 patients, treated betweenDecember 08, 1999 and January 17, 2000 on one pilot ward. Date of analysis was January 17, 2000. Patients aredivided into two groups: ‘discharge group’ with 27 patients already discharged, and ‘in-patient group’ with patientsstill in treatment at the time of analysis. Individual numbers and mean numbers for each group are presented. Thefigures indicate that, after becoming more familiar with the documentation system, the nurses use more predefinedcare plans and modify them more often.


Fig. 5. Use of predefined care plans as a part of the integrated step ‘care planning’ (in gray) within the nursingprocess.

plan must be modified by removing or addingitems.

A nursing reports is written as least at theend of each shift, usually in the form of freetext.

When the patient is dismissed, the wholenursing documentation is added either to theelectronic patients records’ archive, orprinted out and added to the paper-basedrecord.

Fig. 5 presents a summary of the typicaluse of predefined care plans.

4. Prerequisite: acceptance issues

An important prerequisite for the introduc-tion of any new computer-based system isuser motivation and also, some general as-pects such as computer anxiety and attitudestoward computers. Much research has beenconducted dealing with this issues [38–42].

In this chapter, we will concentrate on theaspects specific to the introduction of nursingprocess documentation systems. We will in-clude the topics of acceptance of the nursingprocess as a guideline for nursing care, aswell as the acceptance of the use of comput-ers in nursing which is an issue as computersare said to endanger the individuality of nurs-ing care.

4.1. Acceptance of the nursing process

It has been questioned how the acceptanceof the nursing process influences the successof computer-based nursing process documen-tation support. However, the relationship be-tween the acceptance of the nursing processand successful introduction of computer-based nursing process documentation systemseems to be double-sided. On the one side,nurses, who do not accept the nursing pro-cess as the basis for systematic nursing care,


will not be motivated to use computers since,to them, they seem to increase the documen-tation effort. On the other side, the realiza-tion of the nursing process is difficult whenits documentation is done manually, as docu-mentation efforts and formulation problemswill be high.

We analyzed the acceptance of the nursingprocess before, during and after the introduc-tion of the computer-based nursing processdocumentation system in order to answer thefollowing two questions:� How does the acceptance of the nursing

process change when computer-support isintroduced?

� Is the acceptance of the nursing processa success factor for the introduction ofcomputer-based nursing documentation?It is important to be aware of the fact

that on wards A and B the nursing careprocess had been established for severalyears. In contrast, on ward C and D onlyplanning and documentation of taskshave been documented; care planning orregular achievement reviews of nursingaims were not conducted prior to the intro-duction of computer-support. To answerour questions, we use a standardized, vali-dated questionnaire [43] before, duringand after the introduction of computer-sup-port.

Based on the 18 items of the question-naire, a mean acceptance score for eachnurse was calculated (1=minimum, 4=maximum acceptance). The following arethe results prior to the introduction of com-puter support (mean and standard deviationare presented):� Ward A: 2.7�0.4 (n=11)� Ward B: 3.4�0.3 (n=9)� Ward C: 2.8�0.4 (n=10)� Ward D: 3.0�0.4 (n=11).

The figures show that the acceptance ofthe nursing process is quite high despite the

different implementation of the nursing pro-cess on the four wards. When data fromboth during and after introduction is avail-able, we will test if there is a significantchange in the acceptance scores. Preliminaryresults from wards A and B indicate a sig-nificant increase. The data from wards Cand D will be used to complete this analy-sis.

In seems useful to precede the introduc-tion of computer-based nursing process doc-umentation by such an evaluation of users’acceptance. If low acceptance scores arefound, training courses for the nursing pro-cess should be offered. Without a generalacceptance of the nursing process (as foundon our four pilot wards), the introductionof computer-support may not be successful,as their functionality will not be used orwill be found useless and burdensome.

When looking at the responses in detail,we can see that most nurses are in favor ofthe idea of the nursing process and want touse it, but that the majority thinks it takestoo much time and causes too much writingeffort. With these details in mind, it is clearthat the acceptance scores tend to rise whena computer-based system is introduced, asthe writing efforts and formulation prob-lems will be reduced.

To analyze the importance of this accep-tance score as a success factor, we corre-lated the acceptance of the nursing processwith the overall acceptance of the com-puter-based documentation system after 1year of use. Preliminary results from wardsA and B indicate that the acceptance of thenursing process prior to the study is posi-tively correlated to the acceptance of thecomputer-based system following 1 year ofuse. This indicates that the acceptance ofthe nursing process may be a one factorrelevant for a successful introduction.


4.2. Acceptance of computers in nursing

Some discussion has arisen over the fearthat computers endanger individual patientcare, reduce the time nurses have for patients,and reduce the professional autonomy of thenurses. We analyzed the acceptance of com-puters in nursing before, during and after theintroduction of the computer-based nursingprocess documentation system in order toanswer the following questions:� How does the acceptance of computers in

nursing change when a computer-supportis introduced?

� Is the acceptance of computers in nursinga success factor for the introduction ofcomputer-based nursing documentation?To answer our questions, we use a stan-

dardized and validated questionnaire [44] be-fore, during, and after the introduction ofcomputer-support. Based on the 18 items ofthe questionnaire, a mean acceptance scorefor each nurse was calculated (1=minimum,4=maximum acceptance). The following arethe results before computer-support was in-troduced (mean and standard deviation arepresented):� Ward A: 2.6�0.6 (n=11)� Ward B: 3.0�0.5 (n=9)� Ward C: 2.5�0.6 (n=10)� Ward D: 3.0�0.4 (n=11).

The figures show that the acceptance isquite high. Preliminary results from wards Aand B indicate that these acceptance scoresdid not change during or after introduction.The data from ward C and D will be used tocomplete this analysis.

To analyze the importance of the accep-tance scores as a possible success factor, wecorrelated it with the overall acceptance ofthe computer-based documentation systemafter 1 year of use. Preliminary results fromwards A and B indicate, that the acceptanceof computers in nursing before the study is

not correlated to the acceptance of the com-puter-based system after some time of use.

5. Prerequisite: organizational issues

As much research is being conducted in thefield of organizational issues [28,30], we willconcentrate on organizational issues specificto the introduction of computer-based nurs-ing process documentation in this chapter.

It seems to be helpful to select those wardsas pilot wards in which the nursing process isat least partly accepted. The aims of theintroduction of computer-support should bemade clear. Typical aims are, for example:increase the number of documented tasks asa basis for nursing management, increase thequality of documentation as a basis for qual-ity management, reduce documentation ef-forts for the nurses themselves, increasereusability of documented data for nursingresearch, or improve communication withinthe healthcare professional team. These aimsmay require different project organization, aswell as different functionality and specificpreparation of nursing terminology and pre-defined care plans. To avoid aim conflicts,the aims should be discussed and clearlydefined beforehand.

After the aims are clear and wards havebeen selected, it should not be forgotten toinform and include the non-nursing profes-sionals such as physicians or psychologists.These professionals at least temporarily usenursing documentation as a source of infor-mation. It should therefore be decidedwhether they receive online access to com-puter-based nursing documentation orwhether parts of the documentation will becommunicated in other forms.

The usual documentation processes shouldalso be examined and analyzed with regard tocomputer support. When and where is what


documented by whom? Is computer supportfeasible? Must working processes be changedwhen computer support is introduced?Can, for example, working lists be generatedand applied? Is nursing documentationneeded during physician rounds? In addition,it must be defined what happens with thedata after the patient has been discharged. Inhospitals still using a conventional patientrecord, all relevant information should beprinted out and placed into this record. Inother hospitals, nursing documentationshould be transferred to the electronic recordarchive.

The introduction of computer-based nurs-ing process documentation can be organizedin different steps. The following presents apossible order of steps that can be defined(steps may be left out as required by a ward’spreconditions): First, care plans are createdand printed with the help of the computersystem. During the second step, care plansare maintained within the documentation sys-tem, and no printing is required in this step.The third step involves the documentation oftasks and report writing by the computersystem. Within the fourth step, nursinganamnesis is carried out using computer sup-port. Finally, during the fifth step, the evalu-ation of nursing aims is conducted usingcomputer support.

These steps may be refined, for example, toeffecting an increasing number of patients.This solution allows a slow adoption of thenursing process. It is obvious that the differ-ent steps must be defined and planned before-hand and the realization be monitoredcarefully to ensure success.

It is helpful to have a qualified projectmember to accompany the introduction ofeach step of the nursing process. This enablesto quickly realise whether the staff needsfurther training regarding steps of the nursing

process and will finally help improve thequality of nursing documentation.

6. Prerequisite: technical issues

The technical equipment necessary to in-troduce computer-based nursing process doc-umentation on a ward must be carefullydefined beforehand. The required equipmentdepends on the number of patients andnurses, but also on the documentation andworking processes. For example, a ward us-ing nursing process documentation only inthe ward room may be sufficiently equippedwith two or three computer systems. In con-trast, if nursing documentation is used duringdoctors’ rounds or even by the nurses insidethe patients rooms, either bedside terminalsor mobile computers should be considered toavoid double documentation, data losses anduser frustration. In addition to those comput-ers, other health care professionals must alsobe able to access this new computer-baseddocumentation, thus the function ‘nursingdocumentation’ must also be integrated inthe Health Care Professional Workstation[45] of the non-nursing professionals.

The nursing documentation system mustalso be carefully integrated into the hospitalinformation system [46]. To achieve data in-tegration and to enable exchange of adminis-trative patient data, the software should beinterfaced with the patient management sys-tem. After patient discharge, the nursing doc-umentation should be transferred to theelectronic or conventional patient record.

Finally, it is useful if special nursingknowledge (for example, about the prepara-tion and execution of nursing tasks or aboutsome nursing diagnosis) can be connected tothe information inside the computer-baseddocumentation system, using for exampleweb-based knowledge resources.


7. Discussion

In this paper, we presented some specificprerequisites for the introduction of com-puter-based nursing process documentationsystems. We presented standardization as-pects of nursing terminology, users accep-tance of the nursing process and ofcomputers in nursing, and also some organi-zational and technical issues. We concen-trated on aspects and experiences specific tonursing process documentation.

In our opinion, a high acceptance of thenursing process, a careful preparation of pre-defined care plans (at least partly based onstandardized vocabulary), together with ele-mentary measures such as organizationalpreparation, good project management, in-clusion of future users in the preparationprocess, and sufficient technical equipmentwith integration into the hospital informationsystem are important preconditions for thesuccess of computer-based nursing processdocumentation. This confirms the results ofother studies [47]. In addition, the nursingterminology and the nursing care plans mustbe regularly maintained and updated, takinginto account the development of skills andexperiences of the users.

On our pilot wards, a nursing documenta-tion system has been successfully introduced,despite the different preconditions (for exam-ple, with regard to the previous implementa-tion of the nursing process). The useracceptance is high. The results indicate thatawareness and understanding of the nursingprocess increased on the pilot wards after theintroduction of computer assistance. Com-puter-support of the nursing process cantherefore be regarded as one element of astrategy to integrate the nursing process intothe daily nursing routine.

The analysis of the success factors can berefined when 1 year of experience is available

for all four wards. We will then also be ableto present detailed results concerning the ef-fects of computer-support on quantity andquality of documentation, on working pro-cesses, and on user acceptance.

It can be discussed if our results are trans-ferable to other wards and other depart-ments. We deliberately chose two psychiatricand two (very different) somatic departmentsin order to obtain a broad view of the topic.Despite many differences among the wards,the results and the experiences are very simi-lar. Nevertheless, this assumption should stillbe verified in other surroundings.

Acknowledgements

Such a long-term project is not possiblewithout the help of many people. We wish tothank Friedrich Fellhauer, Torsten Happek,Bettina Hoppe, Marianne Kandert, GiselaLuther, Angelika Tautz and Andreas Wagnerfor their cooperation.

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Documents

Nursing process documentation systems in clinical routine