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Automated nursing documentation: a design perspective.

M D Curtis

    International Journal of Clinical Monitoring and Computing
    |January 1, 1986
    PubMed
    Summary
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    Automated nursing documentation systems, like the Staff Notes Subsystem of the Patient Data Management System (PDMS), offer a workable solution for patient care documentation. This system has been successfully used in critical care units for six years, with ongoing enhancements.

    Area of Science:

    • Health Informatics
    • Nursing Informatics
    • Clinical Information Systems

    Background:

    • Automated nursing documentation systems have been discussed for years.
    • Hewlett-Packard developed the Staff Notes Subsystem of the Patient Data Management System (PDMS).
    • The PDMS has been the primary patient care documentation method in Phoenix Baptist Hospital's Critical Care Units for six years.

    Purpose of the Study:

    • Establish generalized criteria for standardizing the design and evolution of staff notes packages.
    • Discuss the PDMS notes subsystem's structure in relation to these criteria.
    • Present custom modifications and future enhancement recommendations for the PDMS.

    Main Methods:

    • Review of the Staff Notes Subsystem of the Patient Data Management System (PDMS).

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  • Analysis of the system's design and evolution over six years of use.
  • Development of standardized design criteria for automated documentation systems.

    • Main Results:

    • The PDMS meets adequacy and workability criteria for nursing documentation.
    • The system has been successfully implemented and utilized in a critical care setting.
    • Custom modifications have been made to tailor the system to medical staff needs.

    Conclusions:

    • The PDMS serves as a model for effective automated nursing documentation.
    • Standardized criteria can guide the development and improvement of such systems.
    • Continuous evolution based on user needs is crucial for system success.