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Introduction to Nursing Informatics pp 145–176Cite as

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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Author information

Authors and Affiliations

  1. Doctoral Student, Arthur Labatt Family School of Nursing, Western University, London, ON, Canada

    Sally Remus RN, BScN, MScN

  2. Atlantic Branch, Gevity Consulting Inc, Halifax, NS, Canada

    Margaret Ann Kennedy RN, PhD, CPHIMS-CA

  3. Cerner Corporation, Kansas City, MO, USA

    Breane Manson Lucas

  4. Gevity Consulting Inc, Vancouver, BC, Canada

    Tracy Forbes BComm

Authors
  1. Sally Remus RN, BScN, MScN
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  2. Margaret Ann Kennedy RN, PhD, CPHIMS-CA
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  3. Breane Manson Lucas
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  4. Tracy Forbes BComm
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Corresponding author

Correspondence to Sally Remus RN, BScN, MScN .

Editor information

Editors and Affiliations

  1. Calgary, Alberta, Canada

    Kathryn J. Hannah

  2. Dublin City University, Dublin, Dublin, Ireland

    Pamela Hussey

  3. Global Village Consulting Inc, Merigomish, Nova Scotia, Canada

    Margaret A. Kennedy

  4. IBM Research Center for Healthcare Management, Baltimore, Maryland, USA

    Marion J. Ball

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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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