Essay Sample on a New Nursing Documentation System

Published: 2023-01-30
Essay Sample on a New Nursing Documentation System
Type of paper:  Research paper
Categories:  Healthcare Healthcare policy Information systems Nursing care
Pages: 4
Wordcount: 928 words
8 min read

As more technological developments take place in most of the institutions, we have decided on implementing a new nursing documentation system that will be usable and acceptable for both the professionals and patients. This is because we would like to enhance our services and operations such as the creation of a proper patient care plan, research, legal documentation, communication among the professionals of the health system, among others. The application of the recent technology in nursing results from the relations between social acceptance, technical skills as well as the culture in the working environment.

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A new documentation system is required where it will include detailed information of the patient's condition, nursing care plan, progress notes and even diagrams giving a clear description (Wang, Yu & Hailey, 2015). A nurse leader is needed for the responsibility of managing the implementation team to work and achieve the set goal. Nurse leaders are usually essential individuals in the nursing profession who play a significant part in leading the entire healthcare system in its transformation. There is increased demand for nursing leadership today as well as the nursing education and its importance to ensure that it produces professional nurses who indeed will play a significant part in transforming the health system.

Research shows that the primary role of a leader is to influence others through insight and effective communication. Leaders usually have a future vision in which they typically inspire other individuals to pursue. Not all managers who qualify to be leaders but all leaders are managers hence meaning that there are those nurses who can lead without specifically being in management positions. A nurse leader does not require to be recognized by the authority in the organization as a leader since a nurse leader can be any staff member who may help in mentoring new nurses. A nurse leader's primary responsibility is usually to advocate for the profession, patients as well as the nurses (Bender et al. 2016).

This can be through taking actions to promote positive work environments and ensuring proper resource allocation within the system. A nurse leader is someone who provides quality patient care within the healthcare system. A nurse leader should share a vision for excellence, have visibility on the clinical units; they should have visible and active partnerships with the physicians and should emphasize a patient-centered environment. The specialty of a nurse leader oversees the incorporation of patient care, such as management of the patient's medical teams, developing treatment plans, as well as evaluating and collecting treatment results (Cassidy 2016). They lead to disease prevention and health promotion efforts in the healthcare system.

Responsibilities and Duties

The candidate is expected to participate in the implementation and provide impact on the following steps based on the system development life cycle (Stark 2015).

Planning and requirements definition

The candidate is required to identify the scope of the problem and provide solutions in consideration of items such as costs, time, resources, among other things.


Once the possible solutions are provided, the implementation team should take note of the functional requirements of the solution. The candidate should ensure a proper review on the needs of the end-users; in this case, all nurses involved, will be satisfied. A structured analysis, in this case, is needed.

Design of the new system

In this stage, the candidate is required to mobilize the implementation team to discuss and determine their specific needs for the latest documentation system that is to be implemented. The candidate needs to take note, in detail, of the operations, specifications, and essential tools (software and hardware) for the system to achieve its objectives. The implementation team then starts working on the project, and in this case, the nurse leader should provide any training needed by the rest of the nurses to achieve the set objective.


At this stage, the candidate is expected to ensure the installation of the newly-developed nursing documentation system so that the end-users can see the realization of their project. The candidate will ensure that the components and data from the old system will be moved to the new nursing documentation system.

Post-implementation support

The candidate is required to ensure high maintenance of the new system ensure that the regular required updates are adhered to. The candidate is also expected to engage the end-users to find out if there are any additional user requirements.


  • Candidate must have a Bachelor's Degree in Nursing.
  • Must have a current RN license in the state.
  • Candidate should be able to handle multiple assignments simultaneously.
  • The candidate should have the ability to work collaboratively with a large team.
  • The candidate should portray strong leadership skills.
  • The candidate should have excellent written, verbal, and interpersonal communication skills.
  • The candidate should be able to work efficiently under time constraints.


Bender, M., Williams, M., Su, W., & Hites, L. (2016). Clinical nurse leader integrated care delivery to improve care quality: factors influencing perceived success. Journal of Nursing Scholarship, 48(4), 414-422. Retrieved from

Cassidy, Anita. (2016). A practical guide to information systems strategic planning. Auerbach Publications. Retrieved from

Stark, J. (2015). Product lifecycle management. In Product lifecycle management (Volume 1) (pp. 1-29). Springer, Cham. Retrieved from

Wang, N., Yu, P., & Hailey, D. (2015). The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study. International journal of medical informatics, 84(8), 561-569. Retrieved from

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