Wilson D, Nelson N C, Rosebrock B J, Hujcs M T, Wilner D G, Buxton R B
LDS Hospital, Salt Lake City, UT.
Top Health Inf Manage. 1994 May;14(4):24-9.
Nurses at LDS Hospital, Salt Lake City, Utah, have had the ability to document patient data and nursing care on a bedside computer for over nine years. This ability has had numerous ramifications for the medical record, nursing practice, and clinical decision making. This article is an effort to describe how and why certain decisions were made, the implications of these decisions, mistakes that were made and their solutions, and the tremendous impact on clinical decision making and improved patient outcomes that is only beginning to be realized by computerization of the medical record.
犹他州盐湖城LDS医院的护士们在床边电脑上记录患者数据和护理情况已有九年多的时间。这种能力对病历、护理实践和临床决策产生了诸多影响。本文旨在描述某些决策的制定方式及原因、这些决策的影响、所犯的错误及其解决办法，以及病历计算机化对临床决策和改善患者预后产生的巨大影响，而这种影响才刚刚开始显现。
