Siders A M, Peterson M
Department of Nursing, New England Deaconess Hospital, Boston, Massachusetts.
Proc Annu Symp Comput Appl Med Care. 1991:136-40.
At New England Deaconess Hospital (NEDH), identifying nursing diagnoses and collaborative problems treated during the patient's hospitalization and saving this information as part of the computerized core clinical data base is essential to a professional practice model for the delivery of nursing care. Providing the patient with concise, easy-to-read discharge instructions and referral agencies with consistent information about the patient's functional status and directions for patient care are important components of delivering high quality patient care. ODISY (the On-line Deaconess Information System) facilitates an automated nursing discharge summary function in addition to an automated medical discharge summary, interdepartmental communication via order entry and results reporting, and other user designed functions that support patient care. Utilization of this function strengthens the multidisciplinary discharge care planning process, increases patient satisfaction, facilitates the identification of nursing diagnoses and collaborative problems treated by nurses and physicians, saves a significant amount of nursing time in the preparation of discharge information, and enables the hospital to meet Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards and state regulations for discharge planning.
在新英格兰女执事医院（NEDH），识别患者住院期间所接受的护理诊断和合作性问题，并将这些信息作为计算机化核心临床数据库的一部分保存下来，对于护理服务提供的专业实践模式至关重要。为患者提供简洁、易读的出院指导，并为转诊机构提供有关患者功能状态和患者护理指导的一致信息，是提供高质量患者护理的重要组成部分。ODISY（在线女执事信息系统）除了提供自动化的医疗出院小结外，还促进了自动化的护理出院小结功能、通过医嘱录入和结果报告进行的部门间沟通，以及其他支持患者护理的用户设计功能。利用这一功能可加强多学科出院护理计划流程，提高患者满意度，便于识别护士和医生所处理的护理诊断和合作性问题，在准备出院信息时节省大量护理时间，并使医院能够符合医疗组织认证联合委员会（JCAHO）的标准以及出院计划的州法规。
