仔细研究纸质表格上的护理文件记录：为护理文件记录系统计算机化做准备。

A closer look at nursing documentation on paper forms: preparation for computerizing a nursing documentation system.

机构信息

Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, 9500 Gilman Drive #0671, La Jolla, CA 92093-0671, USA.

出版信息

Comput Biol Med. 2011 Apr;41(4):182-9. doi: 10.1016/j.compbiomed.2010.08.006. Epub 2010 Sep 16.

DOI:10.1016/j.compbiomed.2010.08.006

PMID:20846646

Abstract

A small scale documentation analysis was conducted to explore the medical and surgical nursing content of the patient record at a large teaching hospital affiliated with Partners Healthcare System (PHS), in preparation for a computerized documentation system. Through this study, we identified a number of problems associated with the paper record that require resolution in the new computerized system, including elimination of documentation redundancy, areas where more structure is needed to properly capture data on nursing practice, and various design considerations to support a more complete and accurate documentation of nursing care.

摘要

进行了小规模的文档分析，以探索与合作伙伴医疗保健系统 (PHS) 下属的一家大型教学医院的患者记录相关的医疗和外科护理内容，为计算机化文档系统做准备。通过这项研究，我们确定了与纸质记录相关的一些问题，这些问题需要在新的计算机化系统中解决，包括消除文档冗余、需要更多结构的领域，以正确捕获护理实践数据，以及各种设计考虑因素，以支持更完整和准确地记录护理服务。