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Nursing Documentation in Digital Solutions

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Abstract

The imperative of accurate and timely nursing documentation has never been higher than in contemporary professional practice. Increasingly, electronic clinical information systems (CIS) are available in practice settings across the continuum of care to record care. Electronic documentation is not simply the reproduction of paper-based records in a digital format. The design and functionality of solutions in a technology-enabled environment are critical elements to ensure ease of use, alignment to clinical processes, and the achievement of the full range of potential benefits.

Keywords

  • Clinical Information System (CIS)
  • Clinical documentation
  • Interprofessional care teams
  • Point of Care (POC)
  • Point of Service (POS)
  • Workaround
  • Functionality
  • Text notes

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Correspondence to Sally Remus RN, BScN, MScN .

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Remus, S., Kennedy, M.A., Lucas, B.M., Forbes, T. (2015). Nursing Documentation in Digital Solutions. In: Hannah, K., Hussey, P., Kennedy, M., Ball, M. (eds) Introduction to Nursing Informatics. Health Informatics. Springer, London. https://doi.org/10.1007/978-1-4471-2999-8_8

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  • DOI: https://doi.org/10.1007/978-1-4471-2999-8_8

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  • Print ISBN: 978-1-4471-2998-1

  • Online ISBN: 978-1-4471-2999-8

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