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New Nursing Documentation System Implementation


The Digital revolution has brought about exciting revolutions in healthcare which has led to the development of systems that can handle each person’s care, give solutions that are based on facts and evidence, and improve medical records storage. With digital evolution, care can be customized using the existing data in the digital information system. The developments are possible if the stored data is put into good use which leads to making better decisions.

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A nurse plays a very vital role in the treatment process of patients because they constantly interact with the patient during treatment (Bramley & Matiti, 2014). Health information systems have been gaining popularity in the recent past due to their convenience, these systems have impacted the working of nurses as the primary caregivers in the health facilities. Therefore, it is prudent to include them in the development of these systems so that the systems are usable and acceptable to the nurses.

System development cycle (SDLC) is a very important approach in the implementation of health information technology because it can accommodate new changes in the system as it is being developed, the approach takes feedback from end-users and includes it in the development stages to satisfy the needs of the clients (Louis, 2011). The paper is going to describe the role that a graduate-level nurse will be involved in the implementation of a new nursing documentation system.

Planning and implementation

Planning is the most crucial tool that can give a positive outcome to a given project or process. When using the system development life cycle (SDLC) approach, the nurse leading the team of developers has the task of drawing a health care roadmap for them to come up with a customized system to suit the health facility. When it comes to the requirements the nurse is expected to come up with requirements that will lead to the needed outcomes of the system as an output. The developers of the new nursing documentation system will now come up with the code to accept the inputs that are needed.


The analysis stage assesses the processes and workflow the system can handle are evaluated to see if they can be executed properly. The analysis involves testing the system and doing the necessary changes to suit the workplace. In the analysis stage, the lead nurse is expected to give the developers the aspects of the health facility and maybe the attributes of the existing system (Agency for Healthcare Research and Quality, 2019). This will enable the developers to away with unnecessary functions in the code and add useful ones that will meet the requirements of the facility.

Designing the new system

At this level, the actual design is done, and the whole system design is now established and is made based on the issues raised by the lead nurse in the planning and analysis stage. At this level, the implementation crew has decided what the system will be like, and then the team will then come up with prototypes of the system, reports, exhibitions, and screen recordings of the system to identify the possible challenges that the system might pose the end-users(nurses). The role of the lead nurse in this stage is to go through the flowcharts and inspect the prototypes developed by the implementation team to see if they work for the nurses.

Implementation of the system

After the system is designed, it now has to be implemented and serve its purpose, here the student nurse is expected to test the system and see if it satisfies the needs of the documentation system. If the student has some coding skills, they can employ Everest rogers five-step approach to facilitate the implementation using these steps: understanding, persuasion, decision making, actualization, and finally confirmation.

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The student can also use the code flow charts and assist the implementation team in troubleshooting in case of wrong outputs. The lead nurse can choose to schedule meetings with colleagues to get feedback from them and be able to spot the facilitators and limitations of the system. He/she can suggest modifications to the techniques of evaluation of the system and encourage the other nurses to adhere to the system provisions and evaluate the results. The implementation stage should also include training of staff for a smooth transition to the new system.

Post-implementation support

This phase normally involves the use and maintaining the system. The new system should be taken through trials before it is handed over to the health facility Testing is essential in the sense that it ensures that the system takes in the correct input and gives the correct output (McGonigle & Mastrian, 2017). The nurse informaticist is expected to help with ensuring that the system documents the nurses’ data by capturing and storing it correctly for retrieval. He/she is also expected to educate the staff on how to use the system and help them whenever they have problems.


Information technology has had a major role in the transformation of the health sector making it efficient and effective. To ensure the nurses who are the primary caregivers in hospitals have an easy time then the nursing documentation system is very key. The process of developing such a system should follow the system development life cycle approach and be informed by a nurse for a customized system to be developed.


Agency for Healthcare Research and Quality. (2019). Health IT Evaluation Toolkit and Evaluation Measures Quick Reference Guides | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency. Web.

Bramley, L., & Matiti, M. (2014). How does it really feel to be in my shoes? Patients’ experiences of compassion within nursing care and their perceptions of developing compassionate nurses. Journal of Clinical Nursing, 23(19-20), 2790–2799. Web.

Louis, I. (2011). Software Development Life Cycle [SDLC] [YouTube Video]. In YouTube. Web.

McGonigle, D., & Mastrian, K. (2017). Nursing informatics and the foundation of knowledge. In Google Books. Jones & Bartlett Learning. Web.

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