Turley J P
University of Texas Health Science Center, School of Nursing, Houston.
Nurs Outlook. 1992 Jul-Aug;40(4):177-81.
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.
患者病历保存的未来正在当下被构建。随着医疗保健计算机通信标准的发展，关键要素已就位。医学研究所关于计算机化患者病历的报告促使医疗保健领域的许多人重新思考他们的病历保存方法。护士需要审视护理记录的历史，并展望综合护理信息系统的发展。护士与其他学科一起，必须审视他们希望未来的系统涵盖哪些内容。信息系统的一个建议框架有四个主要护理组件：（1）数据存储组件，（2）事务日志，（3）护理决策支持系统，以及（4）一个引擎，用于链接和组合前三个组件，并为护士提供一个一致且易于使用的界面。如果操作得当，这种方法将减少护士用于记录的时间，为他们的记录增添维度，并提高临床实践中数据使用的效率。护理信息系统必须以一种突出优质实践的方式提供信息，同时将护士从耗时的记录工作中解放出来。这些目标是可以实现的，但前提是护士现在就为设计做好规划，以免木已成舟。
