Evidence-Based Proposal and Annotated Bibliography on Technology in Nursing

Electronic Clinical Documentation with Clinical Decision Support

Clinical decision support systems encompass computerized and non-computerized clinical interventions or tools that are essential in the care delivery processes. These systems offer tools for managing information and are essential to electronic health records. These systems thus act as medical information filters that narrow providers’ focus to the relevant information required for clinical remedies (Berner, 2016). This is the reason I selected this topic. Care efficiency is dependent on the flow of information. Accuracy, precision, and shorter downtime during medical information handling are necessary for ensuring efficient care, and electronic health records with clinical decision support systems can guarantee this. This paper seeks to analyze papers targeting electronic documentation and CDSS. These research papers were drawn from databases such as PubMed and Google Scholar. The keywords used were “clinical decision systems” and “electronic documentation.” Several papers obtained were further scrutinized to obtain four sources that are annotated in this paper.

Annotated Bibliography

Baumann, L., Baker, J., & Elshaug, A. (2018). The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy, 122(8), 827-836. DOI: 10.1016/j.healthpol.2018.05.014

This research paper is a systematic review whose primary focus is to establish the impacts electronic health record system has on the time taken to document health records. The authors of this research paper state that the utilization of electronic health records has increased immensely globally over the recent past, with hospitals across many states having fully implemented these systems in their normal operationalization. The impact this electronic system has brought on the time taken to document health information remains unknown. In this review, the authors make a comparison between the time taken for documenting health records before the rollout of this system and after the rollout of this system.

Health records documentation remains a crucial component of healthcare delivery processes. The healthcare providers from all cadres often do documentation. Traditionally, paperwork has been the widespread modality of documentation, with the providers having to document on paper their care processes and clinical outcomes. A review of the time taken on the entire processes by (Baumann, Baker & Elshaug, 2018) of care provided by hospital staff before and after the implementation of this system reveals that this system shortens the documentation time of hospital procedures in the long term.

Electronic health records are digitalized systems that are utilizable in the hospital documentation processes. With their implementation, information flow from the patient to the provider is carried out electronically and, therefore, doesn’t need the time paperwork recording. The benefits of this system are evident in shorter documentation times and, hence, the efficiency of the care process. Additionally, this system maintains a high level of accuracy and reproducibility of medical information by minimizing the loss of information during the relay process. This technology is thus helpful in nursing practice as it preserves information and ensures that the information they get maintains a high degree of validity. It is also crucial to other caregivers as it reduces conflicts that may be attributable to loss or alteration of information during the information relay process.

This publication is essential because it highlights the significance of electronic health records. Its findings reinforce the need for rolling out this system in all healthcare centers. By giving a detailed exhibition of how this system has shortened documentation time, this paper underlines the positive attributes of this system and its ability to enhance the efficiency of the care process.

Sutton, R., Pincock, D., Baumgart, D., Sadowski, D., Fedorak, R., & Kroeker, K. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success. npj Digital Medicine, 3(1). DOI: 10.1038/s41746-020-0221-y

This research paper gives detailed information on the clinical decision support system (CDSS), highlighting its benefits as well as the risks and strategies for the success of its utilization. As mentioned in this paper, CDSS are electronic tools that offer targeted health information and clinical knowledge to care providers, thus enhancing clinical decision-making. The utilization of these systems is often at the point of care, with their significance in enabling t


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