Assessment in a Computer-Based Nursing Documentation

Abstract

Experience in nursing practice shows that, in Austria, there are still problems with assessment in computer-based nursing documentation. Nursing documentation includes the various steps of the nursingprocess and the nursing diagnosis. In addition, an assessment instrument, which captures the needs for care, must also be integrated into it. This chapter describes different Nursing Assessment Instruments and the advantages of Computer-Based Nursing Process Documentation. Quality criteria for assessment instruments are validity, sensitivity, specificity, reliability, practicability, and the appropriateness of the instrument. Quality criteria for computer-based systems are basically software ergonomic aspects, which are not part of this study. Each country should choose for itself those specific assessment instruments that capture the needs for care of their clients. These data enable comparison of facilities and reliable cost estimates in connection with nursing.