Ammenwerth E, Kutscha U, Kutscha A, Mahler C, Eichstädter R, Haux R
Department of Medical Informatics, Institute for Medical Biometry and Informatics, University Medical Center, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
Int J Med Inform. 2001 Dec;64(2-3):187-200. doi: 10.1016/s1386-5056(01)00216-7.
Documentation of the nursing process is an important, but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems, such as low quality and high writing efforts, are reported. However, it is still unclear if computer-based documentation systems can reduce these problems. At the Heidelberg University Medical Center, computer-based nursing process documentation projects began in 1998. A computer-based nursing documentation system has now been successfully introduced on four wards of three different departments, supporting all six phases of the nursing process. The introduction of the new documentation system was accompanied by systematic evaluations of prerequisites and consequences. In this paper, we present preliminary results of this evaluation, focusing on prerequisites of computer-based nursing process documentation. We will discuss in detail the creation and use of predefined nursing care plans as one important prerequisite for computer-based nursing documentation. We will also focus on acceptance issues and on organizational and technical issues.
护理流程记录是临床记录中重要但常被忽视的部分。纸质系统已被引入以支持护理流程记录。然而，人们经常报告诸如质量低和书写工作量大等问题。不过，基于计算机的记录系统是否能减少这些问题仍不明确。在海德堡大学医学中心，基于计算机的护理流程记录项目始于1998年。如今，一个基于计算机的护理记录系统已在三个不同科室的四个病房成功引入，支持护理流程的所有六个阶段。新记录系统的引入伴随着对前提条件和结果的系统评估。在本文中，我们展示该评估的初步结果，重点关注基于计算机的护理流程记录的前提条件。我们将详细讨论预定义护理计划的创建和使用，这是基于计算机的护理记录的一个重要前提条件。我们还将关注接受度问题以及组织和技术问题。
