Clinical Information System: Impacts on Nursing

The purpose of this study was to evaluate the effects of implementing a clinical information system (CIS) in an acute surgical care unit. Nursing output variables examined were proportion of nursing time spent in direct and indirect patient care, and changes in completeness of documentation from patient records according to the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Standard 1.

Work sampling was used to collect information regarding time utilization, by categorizing nursing behavior into 13 operationally defined categories. More than 1600 data points were obtained. Results demonstrated no differences in the proportion of direct versus indirect patient care, and there were no statistically significant differences in the separate categories of nursing behavior. However, there was a statistically non-significant increase in documentation at the bedside from 1% to 3% post- CIS. Completeness of documentation of 53 patients' records was evaluated by peer review. Reviewed charts were scored on each of 22 JCAHO standards. There was a significant (p $lt;0001) increase in documentation completeness after CIS implementation. Further analysis was performed by grouping the 22 JCAHO standards into four clusters; each was analyzed separately to determine if the JCAHO score had changed. In the first cluster, Admission Assessment, there was a statistically non-significant improvement (84% to 94) that increased the JCAHO score from 2 to 1 (the best). In the second cluster, Admission Assessment Factors improved post- CIS from 6% to 94%, and the score increased from 94% to 98% of charts meeting the standard.

These findings indicate that a computerized CIS improves documentation completeness, assists in complying with JCAHO accreditation standards, and provides an audit trail in risk management analysis.