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Computer-based patient record systems
1Cedars Sinai Medical Center, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, USA.
Objectives:
To provide oncology nurses with an overview of computer-based patient record (CPR) systems, a key infrastructure requirement in information management that is essential to maintaining a scientific basis for health care.
Data Sources:
Published articles, research studies, and review articles pertaining to CPR systems.
Conclusions:
Progress in hardware development, software applications, and interfaces combine to bring us multimedia patient record systems. Many obstacles have been overcome as standards have emerged and technologies conform to those standards. However, there has been limited success in implementation of such systems. Early acceptance of structured data and problem-oriented documentation set the framework for charting in the electronic record.
Implications For Nursing Practice:
Oncology clinicians and cancer patients alike will realize greater efficiencies and increased quality in health care when the CPR is fully implemented.
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Health Information Technology and Healthcare Information System
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
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A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Methods of Documentation II: POMR
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:
Methods of Documentation VII: EMR
Integrated Healthcare System
