Computers, informatics, nursing : CIN
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Work sampling measured nurse documentation time before and after the implementation of an electronic medical record on a medical-surgical nursing unit. Documentation was separated into subprocesses of admissions, discharges, and routine/daily documentations. ⋯ Post-electronic medical record documentation time was longer than that in the pre-electronic medical record for patients discharged to a nursing home. It was demonstrated that the electronic medical record may reduce documentation time after the adoption of computerized physician order entry.
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This article describes the development and implementation of a nursing clinical decision support system that prompts nurses to place mechanically ventilated patients in a semirecumbent position in the absence of contraindications. A literature review is provided regarding (1) ventilator-associated pneumonia and recommendations from expert panels to maintain mechanically ventilated patients in a semirecumbent position (unless contraindicated) and (2) clinical decision support systems. ⋯ Despite recommendations from organizations such as the Center for Disease Control and Prevention to maintain mechanically ventilated patients in a head-elevated position, there is evidence that the practice is not adequately adhered to. Therefore, a nursing clinical decision support system (in the form of a reminder) that prompts nurses to adhere to this recommendation was designed and implemented.