Greiner J E
Semin Nurse Manag. 1994 Jun;2(2):72-8.
There have been great strides in developing hospital information systems (HISs); however, there are few if any systems that are fully integrated to allow nursing documentation at microlevel data--that is, information about interventions between a nurse or other health care disciplines and the patient. It consists of the data used by a nurse in taking care of patients at the intervention level. This article suggests a process for developing a fully integrated HIS that will build a nursing minimum data set (NMDS) to aid in case management systems development, costing-out services, and nursing research. The goal of the system is to decrease the amount of paperwork, allowing the nurse to spend more time with the patient, and at the same time improving the quality of documentation and improving patient outcomes.
在医院信息系统（HIS）的开发方面已经取得了巨大进展；然而，几乎没有（如果有的话）完全集成的系统能够支持微观层面的数据护理记录，即护士或其他医疗保健学科与患者之间干预措施的信息。它由护士在干预层面照顾患者时使用的数据组成。本文提出了一个开发完全集成的HIS的过程，该过程将构建一个护理最小数据集（NMDS），以协助病例管理系统的开发、服务成本核算和护理研究。该系统的目标是减少文书工作量，使护士有更多时间陪伴患者，同时提高记录质量并改善患者预后。
