Implementing Electronic Patient Record and VIPS in medical hospital wards : Evaluating change in quantity and quality of nursing documentation by using the audit instrument Cat - ch - Ing

Aim: The study examines the effectiveness of implementation of electronic nursing documentation and the nursing documentation system VIPS at the Department of Medicine, and also aims to improve our understanding of content and quality in nursing documentation. Background: After introducing Electronic Patient Record (EPR) and VIPS to medical wards, change in the quantity and quality of nursing documentation was evaluated by using the audit instrument Cat-ch-Ing. Method: Cat-ch-Ing is adjusted to fit medical wards. 15 patient records are reviewed before and 15 records after introduction of EPR and VIPS in each of the four included wards (n=120). The paper records’ scores are compared to scores in the EPR’s and analyzed by Mann-Whitney test. Findings: We find more systematic and standardized documentation when using VIPS keywords, and limited use of abbreviations and symbols when the documentation is electronic. Documentation of the nursing process in the VIPS model, especially nursing care plans are inadequate. Conclusions: Nurses need further education in VIPS to learn how to use it fully. Also the EPR needs enhanced adaptation to fulfil nursing documentation requirements. Cat-ch-Ing was an adequate instrument in this study, but further development is recommended.