Assessment in a Computer-Based Nursing Documentation
Elfriede Fritz (University of Health Sciences - Medical Informatics and Technology, Austria), Daniela Deufert (University of Health Sciences - Medical Informatics and Technology, Austria) and Johannes Hilbe (University of Health Sciences, Medical Informa)
Copyright: © 2009
Experience in nursing practice shows that, in Austria, there are still problems with assessment in computer-based nursing documentation. Nursing documentation includes the various steps of the nursingprocess and the nursing diagnosis. In addition, an assessment instrument, which captures the needs for care, must also be integrated into it. This chapter describes different Nursing Assessment Instruments and the advantages of Computer-Based Nursing Process Documentation. Quality criteria for assessment instruments are validity, sensitivity, specificity, reliability, practicability, and the appropriateness of the instrument. Quality criteria for computer-based systems are basically software ergonomic aspects, which are not part of this study. Each country should choose for itself those specific assessment instruments that capture the needs for care of their clients. These data enable comparison of facilities and reliable cost estimates in connection with nursing.
According to Gottschalck (2003), assessments are carried out by nurses in order to gather basic data such as at admission of a patient to a hospital or a client to a nursing home or home care. Assessment serves the purpose of establishing the individual nursing needs of clients. Assessments simplify nursing documentation, help avoid unnecessary measures in relation to patients, enable estimation of individual reactions of clients to nursing care and facilitate monitoring of effectiveness of nursing (Gottschalck, 2003).