Computer charting: an evaluation of a respiratory care computer system.

A respiratory care computer-charting system was developed and implemented as an addition to our hospital's computerized information system. Medical personnel charted and reviewed respiratory care procedures at nursing station computer terminals instead of using the patient's traditional paper chart. The computer automatically performed billing and provided management as well as clinical information. In an attempt to isolate specific benefits or shortcomings, we evaluated charting systems both before and after computer implementation. Four assessments were made: (1) a survey of therapists' attitudes, (2) an observation of work patterns, (3) an audit of the content of charting, and (4) an analysis of productivity statistics. Computer charting was well accepted by therapists. Charge capture was reduced from a four-step manual process to a single-step computer documentation of the procedure. Computer charting was more complete and informative. Productivity increased 18%, although it remains unclear to what degree the computer was responsible. Computer charting streamlined the process of documentation and allowed more beneficial use of clinical information.