Comput. Biol. Med. - A closer look at nursing documentation on paper forms: preparation for computerizing a nursing documentation system.

Tópicos

{ record(1888) medic(1808) patient(1693) }
{ care(1570) inform(1187) nurs(1089) }
{ take(945) account(800) differ(722) }
{ studi(2440) review(1878) systemat(933) }
{ sampl(1606) size(1419) use(1276) }
{ imag(1057) registr(996) error(939) }
{ problem(2511) optim(1539) algorithm(950) }
{ research(1218) medic(880) student(794) }
{ cost(1906) reduc(1198) effect(832) }
{ sequenc(1873) structur(1644) protein(1328) }
{ patient(2315) diseas(1263) diabet(1191) }
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{ detect(2391) sensit(1101) algorithm(908) }

Resumo

A small scale documentation analysis was conducted to explore the medical and surgical nursing content of the patient record at a large teaching hospital affiliated with Partners Healthcare System (PHS), in preparation for a computerized documentation system. Through this study, we identified a number of problems associated with the paper record that require resolution in the new computerized system, including elimination of documentation redundancy, areas where more structure is needed to properly capture data on nursing practice, and various design considerations to support a more complete and accurate documentation of nursing care.

Resumo Limpo

small scale document analysi conduct explor medic surgic nurs content patient record larg teach hospit affili partner healthcar system phs prepar computer document system studi identifi number problem associ paper record requir resolut new computer system includ elimin document redund area structur need proper captur data nurs practic various design consider support complet accur document nurs care

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