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Findings also suggest that a computerized clinical documentation system that specifically tracks nursing practice is vital if nurses are to identify and eventually be reimbursed for client care specific to nursing practice.
In this study, selected data from an 11-year clinical data set are presented to show the scope of academic CNC nursing practice, describe client services and expanded nursing roles, show the use of a computerized clinical documentation system in tracking nursing practice, and assess the usefulness of the Lundeen conceptual model.
Legally, it is part of the local clinical documentation system.
CDS – computerized clinical documentation system Decision Support Database – a collection of information about the patients that the clinician's have decided to save in order to ask global questions about groups of patients.
The development of standardized provincial prenatal records offers an intriguing example of health policy decision-making, particularly as the forms function as both national practice guidelines and as a mandatory clinical documentation system.
To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity.
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Computerized clinical documentation systems (CDS) provide for the documentation of patient care using computers.
Clinical documentation systems have been shown to influence processes of care in many different settings[ 1- 7].
Another major benefit of computerized clinical documentation systems is a reduction of medication errors [ 5].
Clinical documentation systems, such as templates, have been associated with process utilization.
It is likely that with the introduction of greater computerisation, for example with computerised medication management and clinical documentation systems, time spent completing tasks with a computer will increase substantially.
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