Pryor T A
Medical Biophysics and Computing, University of Utah/LDS Hospital, Salt Lake City 84143.
Int J Clin Monit Comput. 1989 Jul;6(3):173-9. doi: 10.1007/BF01721030.
Computerized nurse charting programs have been used at LDS Hospital for over two years. These programs allow the nurse to create nurse care plans for the management of the patient, and chart on the computer actions and information which support the documentation of the management of the patient according to the care plan created for the patient. Computer terminals have been placed at the patient's bedside to facilitate the use of these programs. This paper describes the programs available at LDS Hospital and several evaluation studies which have been performed to measure the efficacy of the programs. The evaluation studies indicated an increase in the level of documentation completeness and accuracy by the nurse but at some minor expense to time available to the nurse for patient care. Evaluation of the need for bedside terminals versus centrally located terminals showed an overwhelming desire by the nurse in favor of the bedside terminal. It was also found that data was entered more timely with less waiting when bedside terminals were available. Physician acceptance of the nurse charting system was found to be favorable.
计算机化的护士记录程序在LDS医院已经使用了两年多。这些程序允许护士为患者管理创建护理计划，并在计算机上记录支持根据为患者创建的护理计划对患者管理进行记录的行动和信息。计算机终端已放置在患者床边，以方便这些程序的使用。本文描述了LDS医院可用的程序以及为衡量这些程序的功效而进行的几项评估研究。评估研究表明，护士记录的完整性和准确性有所提高，但在一定程度上减少了护士用于患者护理的时间。对床边终端与集中式终端需求的评估表明，护士强烈倾向于使用床边终端。还发现，有床边终端时，数据输入更及时，等待时间更短。医生对护士记录系统的接受度良好。
