Curtis M D
Int J Clin Monit Comput. 1986;3(3):199-209. doi: 10.1007/BF01716362.
The concept of an automated nursing documentation system has been subject to casual debate for a number of years. During this time, Hewlett-Packard developed a system that is both adequate and workable from many perspectives (i.e. the Staff Notes Subsystem of the Patient Data Management System-PDMS). This package has been used as the primary method to document patient care for six years in the Critical Care Units of Phoenix Baptist Hospital. With the aid of Baptist Hospitals and Health Systems (BHHS) Design Engineers, it continues to evolve predicated on a singular intent: To provide the type of documentation required by the medical staff. The objective of this paper is multifold. Foremost, generalized criteria are established to provide a vehicle for standardizing the design or evolution of a staff notes package. The generic structure of the PDMS notes subsystem is discussed in regard to its parity with these criteria. Finally, custom modifications and additions to this package will be presented, and recommendations for future enhancements will be outlined.
自动化护理文档系统的概念已经历了数年的非正式讨论。在此期间，惠普公司开发了一个从多个角度来看都足够且可行的系统（即患者数据管理系统 - PDMS的护理记录子系统）。该软件包在凤凰浸信会医院的重症监护病房中作为记录患者护理的主要方法已经使用了六年。在浸信会医院及卫生系统（BHHS）设计工程师的帮助下，它继续基于一个单一意图发展：提供医务人员所需的文档类型。本文的目标是多方面的。首先，建立通用标准，为规范护理记录软件包的设计或演进提供一种手段。将讨论PDMS记录子系统的通用结构与这些标准的一致性。最后，将介绍对该软件包的定制修改和添加内容，并概述未来增强功能的建议。
