Nursing documentation in the computer-based patient record

This paper describes the INFORMM NIS (Information Network for On-line Retrieval & Medical Management Nursing Information System) charting system developed by the Departments of Nursing and Information Systems at the University of Iowa Hospitals and Clinics (UIHC). The documentation system features automated work lists, defaulted charting responses, decision support, automatic computations, chart forms and reports, and graphical displays of clinical data. The impact of the on-line charting system has been demonstrated by content standardization with Nursing Interventions Classification (NIC), improved standards compliance, increased efficiency, enhanced timeliness, expanded accessibility, and an augmented data archive.