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.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Canada. College of Nurses of Ontario (CNO). Practice standard: documentation, revised 2008. Toronto: The Standard of Care; 2008. pp. 1–12.
Blair B, Smith B. Nursing documentation: frameworks and barriers. Contemp Nurse. 2012;41(2):160–8.
Tornvall E, Wilhelmsson S. Nursing documentation for communicating and evaluating care. J Clin Nurs. 2008;17:2116–24.
Page A. Practice implications of keeping patients safe. In: Hughes R, editor. Patient safety and quality: an evidenced-based handbook for nurses. Rockville: Agency for Healthcare Research and Quality; 2008. pp. 609–20. Retrieved: www.ahrq.gov/qual/nurseshdbk/nurseshdbk.pdf.
Kramer M, Maguire P, Brewer B. Clinical nurses in Magnet hospitals confirm productive, healthy unit work environments. J Nurs Manag. 2011;19:5–17.
Maiden J. Is your work environment healthy? Nurs Manage. 2010;41(11):36–9.
Pringle D, Nagle L. Leadership for the information age: the time for action is now. Nurs Leadersh (Tor Ont). 2009;22(1):1–6.
Kennedy M, Remus S. Chief nursing information officers: key roles and competencies in effective health informatics leadership. eHealth Vancouver; 2012.
Waneka R, Spetz J. Hospital information technology systems’ impact on nurses and nursing care. J Nurs Adm. 2010;40(12):509–14.
Tyler D. Administrative and clinical health information systems. In: McGonigle D, Mastrian K, editors. Nursing informatics and the foundation of knowledge. Sudbury: Jones and Bartlett; 2009. p. 205–18.
Hughes S. Point-of-care information systems: state of the art. In: Ball M, Hannah K, Newbold S, Douglas J, editors. Nursing informatics: where caring and technology meet. New York: Springer; 2000. p. 242–51.
Pare G, Moreault M, Poba-Nzaou P, Nahas G, Templier M. Mobile computing and the quality of home care nursing practice. J Telemed Telecare. 2011;17:313–7.
Varpio L. Electronic patient records and professional practices: a rhetorical analysis of the impact of changing media and interface design. Paper presented at London Health Sciences Centre – Nursing Professional Practice Council, London, 2005.
Canada. College of Nurses of Ontario (CNO). Struggling with electronic documentation. The Standard. 2012;37(1):18–9.
Kelley T, Brandon D, Docherty S. Electronic nursing documentation as a strategy to improve quality patient care. J Nurs Scholarsh. 2011;43(2):154–62.
Ball M, Hannah K, Newbold S, Douglas J, editors. Nursing informatics: where caring and technology meet. 3rd ed. New York: Springer; 2000.
Monegain, B. “EHR usability: A love/hate relationship.” HIMSS and Healthcare IT News 2012;9(10): 4–6,8. Retrieved November 12, http://www.HealthcareITNews.com.
Remus S, Kennedy M. Innovation in transformative nursing leadership: nursing informatics competencies and roles. Nurs Leadersh (Tor Ont). 2012;25(4):14–26.
Remus S. RNs participating at the policy table. Canadian Nursing Informatics Association Conference – Nurses & Informatics: Transforming Healthcare, Toronto, 10 Sept 2005.
Lunney M, Delaney C, Duffey M. Advocating for standardized nursing languages in EHRs. J Nurs Adm. 2005;35(1):1–3.
Advanced Care Documentation. Kansas City, Missouri, U.S.A: Cerner Corporation; 2009 (copyright 2009–2011). Available: https://store.cerner.com/items/200.
CareCompass. Kansas City, Missouri, U.S.A: Cerner Corporation; 2009 (copyright 2009–2011). Available: https://store.cerner.com/items/1482.
Inpatient Summary. Kansas City, Missouri, U.S.A: Cerner Corporation; 2009 (copyright 2009–2011). Available: https://store.cerner.com/items/284.
Lighthouse Performance Improvement. Kansas City, Missouri, U.S.A: Cerner Corporation; 2009 (copyright 2009–2011). Available: https://store.cerner.com/items/242.
Discharge Readiness. Kansas City, Missouri, U.S.A: Cerner Corporation; 2009 (copyright 2009–2011). Available: https://store.cerner.com/items/173.
White P, Remus S. Health outcomes for better information and care: making nursing visible. HIMSS’09 – Nursing Informatics Symposium: Leaders Optimizing Healthcare Outcomes through Informatics, Chicago, 4 April 2009.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
Copyright information
© 2015 Springer-Verlag London
About this chapter
Cite this chapter
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
Download citation
DOI: https://doi.org/10.1007/978-1-4471-2999-8_8
Published:
Publisher Name: Springer, London
Print ISBN: 978-1-4471-2998-1
Online ISBN: 978-1-4471-2999-8
eBook Packages: MedicineMedicine (R0)