ABSTRACT
A project to fully implement a novel computerized nursing records system resulted in the standardization of nursing records, reduced the administrative workload for staff, enabled medical staff to know a patient's status at any given time, and improved the quality of nursing care provided to patients. The development process of the computerized nursing records system involved three main steps: 1) the establishment of a new nursing assessment form and introduction of nursing diagnosis into routine work, 2) computerized system design and construction, and 3) the usability check of the computerized nursing records system in a clinical setting for 1 year. The successful development of the computerized nursing records system was based on the following points: 1) the assessment form for nursing diagnosis was improved and the nursing diagnosis was introduced before the computerized system was designed and constructed; 2) full, rather than partial, implementation of the computerized system occurred; 3) existing knowledge of nursing assessments and standard care planning were fully used; 4) registered data were optimally reused upon summarization and readmission to reduce the nurses' workload; and 5) portable computers were introduced to enable simple and quick recording of bedside findings. The routine use of the computerized nursing records system was started in April 2000. More comprehensive investigations during the next 2 to 3 years are necessary to determine how the contents of nursing records can be improved and how much the computerized nursing records system affects the quality of nursing.
