Gluck J
J Nurs Adm. 1979 Dec;9(12):17-24.
A system of computerized medical record-keeping in a health maintenance organization is described. Some problems arising in the shift from manual to computerized record-keeping are discussed. Perhaps the most important for nursing is the increase in the nursing staff's responsibility for complete, consistent documentation of patient care concomitant with the shift to a computerized system. Nurses must be comfortable with patient assessment, patient management and documentation in order to utilize the system effectively.
本文描述了健康维护组织中的计算机化医疗记录保存系统。讨论了从手工记录保存向计算机化记录保存转变过程中出现的一些问题。对护理工作而言，或许最重要的是，随着向计算机化系统的转变，护理人员在完整、一致地记录患者护理情况方面的责任增加了。护士必须熟悉患者评估、患者管理和记录，以便有效地使用该系统。
