Improving health care worker’s compliance with traceability by recording the nursing process at the point of care using a personal digital assistant with a barcode

ABSTRACT Background Adverse events are serious and frequent complications most often linked to the quality of nursing care. Purpose We evaluated the compliance to traceability of nursing care at bedside using the Patient Smart Reader®, a personal digital assistant with a barcode. Methods We compared paper record forms, specific computer software in the hospital information system and the Patient Smart Reader®. Results The Patient Smart Reader enhanced the recording of 90% of nursing care surveyed. Regarding the insertion of blood catheters, compliance rates increased from 44.19 % to 100%, and blood catheter monitoring has risen from 29.64% to 80.74%. Urinary catheter monitoring and insertion recording increased from 10.23% to 55.43% and from 16.67% to 100 % respectively. Conclusions Providing to caregivers a nursing record system using barcoded implements at the point of care in real time significantly improved traceability of the nursing care.