On-line documentation of patient care orders.

The INFORMM NIS (Information Network For Online Retrieval & Medical Management Nursing Information System) provides on-line documentation of patient care orders. These orders, generated by the nurse or the physician, prescribe direct patient care and do not include interdepartmental orders such as laboratory, radiology, or pharmacy. The order charting functions support charting efficiency by defaulting previous responses so that the user enters only updates to earlier findings or new data. Available in tables maintained by NIS staff, charting responses provide decision support by suggesting valid results for each order. Using point-of-care devices, nursing staff chart patient data that are immediately available for review by all authorized members of the health care team. These data are printed automatically on computer-generated chart forms every twenty-four hours, but may be printed also on demand. Additionally, the patient data report, containing patient data entered on-line in the sixteen or twenty-four hours immediately preceding the print request, provides a summary that is useful for nurses' report and physicians' rounds.