Stoupa R, Warren J J, Bonk J E, Campbell J R
Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-3333.
Proc Annu Symp Comput Appl Med Care. 1991:941-2.
The ambulatory office setting is increasingly becoming a central focus of patient care. The nursing staff are integral to patient care management in this environment. They are frequently the heaviest users of medical records and are generally early advocates of well designed computer records systems. As our implementation of a Computer Stored Ambulatory Record (COSTAR V) has grown in complexity and utility, reorganization of the record and development of new features to support nursing has become critical. This demonstration will show how nursing information management has changed using a variety of computer record tools, including features of exam room data entry, specialized nursing displays and problem based patient summaries. Specific items for demonstration will include: nursing check-in module, rule driven nursing history program, prescription refill functions, documentation and billing for nursing procedures, nursing telephone management functions, a module for management of anticoagulation and document retrieval and display utilities.
门诊办公室环境日益成为患者护理的核心关注点。在这种环境下，护理人员是患者护理管理不可或缺的一部分。他们经常是医疗记录的最大使用者，并且通常是设计良好的计算机记录系统的早期倡导者。随着我们对计算机存储门诊记录（COSTAR V）的实施在复杂性和实用性方面不断发展，记录的重组以及开发支持护理的新功能变得至关重要。本次演示将展示如何使用各种计算机记录工具来改变护理信息管理，包括检查室数据录入功能、专门的护理显示以及基于问题的患者摘要。演示的具体项目将包括：护理登记模块、规则驱动的护理病史程序、处方 refill 功能、护理程序的文档记录和计费、护理电话管理功能、抗凝管理模块以及文档检索和显示实用程序。
