Discussion: Nursing Documentation System

The documentary system of nurses plays a rather important place in the process of providing health services. Access to clinical information plays a unique role in the decision-making process related to the well-being of patients. To ensure the safety and proper use of medical data, it is necessary to develop a specialized system. Therefore, this work aims to study the systems development life cycle as part of health information technology. In addition to the steps that are used in this approach, the role of nurses and how they are involved in this process will be considered.

Thus, initially, it is necessary to gain an understanding of what nursing documentation is. This is data that a medical organization collects not only about patients but also about nurses. In other words, it is “written evidence demonstrating that the nurse’s authorized and moral responsibilities were met in order for care to be assessed” (Shafiee et al., 2022, p. 1). Thus, the documentation helps to significantly improve the process of help and care while providing a rapid exchange of information using specialized information systems.

The main aspects that must be observed in the implementation of system development are precision, time, conciseness, organization, and confidentiality. These features will help improve the results of medical services while improving the quality and productivity of employees. Moreover, the implementation of the nurse documentation system will provide greater accessibility and accountability of healthcare practices and significantly contribute to the development of communication between healthcare stakeholders (Shafiee et al., 2022). Therefore, the introduction of new technologies to ensure the storage and transmission of clinical data is of critical importance.

There are other reasons that cause a severe attitude toward such an aspect as nursing documentation and the life cycle of its development system. Thus, they may include the need for comprehensive documentation of nursing interventions since they involve various kinds of actions. Hence, among them, there are various assessments, planning, implementation, and evaluation. In these processes, nurses are required to fill out particular forms that will contain basic information about patients and their diseases. All of them will later be recorded in specialized programs for storing this information to facilitate data recording.

Involvement in the work on the introduction of information technologies in the process of providing health services to nurses is critically essential. This is because they can significantly facilitate the process of incorporating new technologies into practice (Heidarizadeh et al., 2017). This aspect is precious when developing a systems development life cycle. This concept includes a management framework that can improve the quality of information systems in healthcare and other areas of people’s lives. The value of this development is due to ensuring the durability and efficiency of the new technology. The role of a nurse acquires guiding characteristics since it mainly consists of participation in the implementation team. Henceforth, it is necessary to discuss the importance of this specialist based on the system development lifecycle stages and tasks that this individual should perform to impact the results.

The first stage in the life cycle of the system is the process of planning and requirements definition. It includes the creation of a draft of the future system, taking into account all the necessary conditions and mandatory aspects. Moreover, at this stage, there is an assessment of possible risks that the staff and the organization may face in the process of implementing the technology (Daoudagh & Marchetti, 2020). The role of the leader nurse at this stage is to lead a team in researching and collecting information. Then, there is an analysis of the data obtained and the draft compiled, in which the nurse leader can help by making edits based on practice.

Consequently, the new system’s design takes place according to the changes and corrections made. At this stage, possible problems and risks are already being studied in more detail, with the solution of which the leader of the team of medical specialists can help. Implementation is one of the most critical and severe steps in the entire lifecycle. At this step, the advantages and disadvantages of the system and possible adjustments can be distinguished. With post-implementation support, there is constant monitoring of the implemented information, data about which will be provided by the group and the nurse leader, who will coordinate this work.

Further, for a more successful implementation of health information technology, it is necessary to create specialized teams with a nurse leader who will ensure the innovation implementation process. The importance of such a leader is manifested in the fact that nurses are among the most mobile, and at the same time, there are many knowledgeable specialists who are incredibly knowledgeable about all the components of clinical care. That is why the main advantage of involving a nurse leader on an implementation team for health information technology is that this specialist can give valuable insight into working in a medical institution. However, the disadvantage may be the wrong choice of leader, which can lead to undesirable results.

References

Daoudagh, S., & Marchetti, E. (2020). A life cycle for authorization systems development in the GDPR perspective. ITASEC, 128-140.

Heidarizadeh, K., Rassouli, M., Manoochehri, H., Tafreshi, M. Z., & Ghorbanpour, R. K. (2017). Nurses’ perception of challenges in the use of an electronic nursing documentation system. CIN: Computers, Informatics, Nursing, 35(11), 599-605. Web.

Shafiee, M., Shanbehzadeh, M., Nassari, Z., & Kazemi-Arpanahi, H. (2022). Development and evaluation of an electronic nursing documentation system. BMC Nursing, 21(1), 1-12. Web.

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