A randomized evaluation of a computer-based nursing documentation system

A two-month randomized, controlled trial based on 60 patients has been perf ormed on a ward of the Department of Psychiatry at Heidelberg University Me dical Center, Germany, to investigate the influence of computer-based nursi ng documentation on time investment for documentation, quality of documenta tion and user acceptance. Time measurements, questionnaires, documentation analysis and interviews were used to compare patients documented with the c omputer-based system (PIK group) with the control group (patients documente d with the paper-based system). The results showed the advantages and disad vantages of computer-based nursing documentation. Time needed for nursing c are planning was lower in the PIK group. Some formal aspects of quality wer e considerably better in the PIK group. On the other hand, time required fo r documentation of tasks and for report writing was greater in the PIK grou p. User acceptance increased significantly during the study. The interviews indicated a positive influence of PIK on the cooperation between nurses an d physicians.