An automated nursing assessment for a teaching hospital

An automated nursing assessment has been developed by the Department of Nursing and the Center for Clinical Computing at Beth Israel Hospital and Harvard Medical School. Designed to collect standardized data using structured and free-text entry of patient-specific data, the program has been in use on all medical and surgical inpatient units since July 1994. Before it was implemented, each nursing unit had used its own format to document the nursing assessment and there was no standardization of information. The automated system has decreased repetitive entry of data items, improved the legibility and availability of baseline information, increased patient-related communication between nursing units, and reduced the average time spent documenting the admission assessment from 60 to 30 minutes.