The effect of a computerized nursing care plan model on the planning, implementation, and evaluation of nursing care.

The Nursing; care plan is a tool which can be used by the professional nurse to direct patient care, guide documentation of care, and establish and promote continuity of care. The purpose of this study was to compare utilization of traditional and computerized Nursing; care plans and their effects on the planning, implementation, and evaluation of Nursing; care. Patient records from four Nursing; are units, two medical and two surgical, were audited. One unit from each pair was designated an experimental group; the other unit became the control group. Audits were conducted before and after implementation of a computerized Nursing; care plan (NCP) model. A total of 192 patient records was randomly selected and audited (96 per each data collected period). Descriptive statistics, t-test, and correlations were completed to determine the effect of the computerized NCP model one: a) the number of NCPs written; b) the number of patient problems identified per NCP; and c) the number of patient problems, Nursing; interventions, and evaluations documented in the nurses notes. The experimental and control groups were compared. Additionally pre- and post-audit measures of the medical and surgical groups were compared. The results demonstrated a significant change for the surgical experimental group after the computerized NCP model was implemented. This group had significant increases in number of NCPs constructed, number of patient problems identified per NCP, and number of evaluations per intervention documented after the computer NCP model had been implemented. Limitation to the study precludes inferring causality. The findings indicate a need for further research, education, and action regarding use of computerized NCPs in Nursing; practice.