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[Integration of a software for hospital nutritional support prescription and the electronic medical record]
José Joaquín Alfaro Martínez1, Mariano López Díaz, Antonio Hernández López
1Servicio de Endocrinología y Nutrición.
Introduction:
The prescription of parenteral nutrition is a medical procedure that should be properly documented and that requires adequate communication between physicians, pharmacists and nurses. Prescription may be made by orders and paper forms or with software applications, in which case their integration with the rest of the hospital information systems may be difficult. We present our experience with a software for prescribing artificial nutrition integrated with the electronic medical record.
Methods:
In order to develop a software application for artificial nutrition prescription, meetings between the Clinical Nutrition Unit and the Computing Service staff were held, which set the needs of the clinical services and features that should have the application. DESCRIPTION OF THE SOFTWARE: The software allows the prescription of parenteral nutrition component by component or using predesigned templates, generates alerts if extreme value of components or possible physical- chemical incompatibility, imports and stores the results of the labs of patients and records the composition of parenteral nutrition formula in the electronic medical record, among other features.
Discussion:
Our experience shows that collaboration between clinical services and hospital Computing permits to develop useful applications for the clinical teams and that can be integrated with other hospital software.
Related Concept Videos
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:
Nursing Clinical Information System
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:
Integrated Healthcare System
Methods of Documentation VII: EMR
Purpose of Health Records II
Guidelines and Strategies for Safe Computer Charting
Maintain Confidentiality and Security:

