A framework for the transition from nursing records to a nursing information system.

The future of patient record keeping is being developed now. Critical aspects are in place with the development of computer communication standards for health care. The Institute of Medicine's report on the computerized patient record has galvanized many in the health care field to rethink their methods of record keeping. Nurses need to examine the history of the nursing record and look toward the development of a comprehensive nursing information system. Nurses, along with the other disciplines, must examine what they want the system of the future to encompass. A suggested framework for the information system has four major nursing components: (1) data storage component, (2) transaction log, (3) nursing decision support systems, and (4) an engine to link and combine the first three components and to present a consistent easy-to-use interface to the nurse. Done properly, this approach will reduce the amount of time nurses spend charting, add dimension to their notation, and increase the efficiency of data usage for clinical practice. The nursing information system must allow information availability in a manner that accentuates quality practice while releasing the nurse from time-consuming record keeping. These goals are possible to meet, but only if nurses plan for the design now, before it becomes a fait accompli.