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Related Experiment Videos

The computerized notation system: a portable, self-contained system for entry of physicians' and nurses' notes.

S R Ash, S L Mertz, D K Ulrich

    Journal of Clinical Engineering
    |March 12, 1983
    PubMed
    Summary

    The Computerized Notation System (CNS) offers a portable solution for clinical documentation, simplifying physician and nurse note-taking. This system enhances patient record organization and legibility in various healthcare settings.

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    Area of Science:

    • Medical Informatics
    • Clinical Computing
    • Healthcare Technology

    Background:

    • Physician and nurse documentation is critical for patient care but often hindered by system limitations.
    • Existing systems pose challenges like keyboard access, typing proficiency, and immediate output.
    • The need for efficient, legible, and integrated clinical note-taking systems is paramount.

    Purpose of the Study:

    • To introduce and evaluate the Computerized Notation System (CNS) for clinical documentation.
    • To assess the CNS's ability to streamline physician and nurse written communications.
    • To determine the system's impact on the problem-oriented approach to patient care.

    Main Methods:

    • Development of a portable microprocessor system (CNS) for bedside and clinic use.

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  • Design addressing issues of keyboard access, typing skills, and printout immediacy.
  • Integration with existing hospital and clinic paper chart systems.

    • Main Results:

    • The CNS produces physician and nurse communications with bedside or in-room printout.
    • The system simplifies and encourages the problem-oriented approach, yielding organized, legible notes.
    • Clinical trials confirmed the CNS's applicability, variability, and acceptability in diverse practice settings.

    Conclusions:

    • The Computerized Notation System (CNS) is a viable tool for improving clinical documentation.
    • CNS enhances efficiency and legibility of patient records in hospitals and outpatient clinics.
    • The system's design overcomes common barriers to computer entry for healthcare professionals.