Electronic Nursing documentation

Studies, referring to nursing documentation, accentuate the problem of insufficient and erroneous nursing record. Aiming at the safety of patients, the improvement of quality of health care provided, the reduction of cost of health services, the increase of patients’ and nurses’ satisfaction and the consolidation of nursing work, although many efforts were made to improve nursing documentation with the use of evolved printed forms, the problem still remains. The solution that appears is the use of technology and the establishment of electronic documentation. The use of computers decreases the errors in health care, mainly with the support to the decision-making, legibility of the registered elements and the abolition of copying. Also, they limit the time, that is required by the process of documentation and permit authorized users to have direct access in patient’s data. The transit from the paper-based documentation to automated documentation cannot happen automatically, because change is not made without inconvenience, even from worse to better. The participation of nurses in the analysis of requirements, in planning and installation of information technology applications, in their working place, is compulsory, so that these applications meet the user’s needs and consequently ensure their success.