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Related Experiment Videos

Computer based nursing documentation means to achieve the goal

T Bürkle1, A Michel, W Horch

  • 1Institute for Medical Informatics, University of Giessen, Germany.

International Journal of Medical Informatics
|December 16, 1998
PubMed
Summary
This summary is machine-generated.

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Giessen Hospital Information System WING now fully supports Therapeutic Intervention Scoring System (TISS) classification for all intensive care patients. This integration enhances patient data accuracy and supports future electronic health record development.

Area of Science:

  • Health Informatics
  • Critical Care Medicine
  • Nursing Informatics

Background:

  • Health insurance demands for accurate ICU bed classification necessitated improved documentation.
  • The Giessen Hospital Information System WING was enhanced to support patient classification.
  • Initial implementation focused on a single intensive care unit.

Purpose of the Study:

  • To detail the integration of Therapeutic Intervention Scoring System (TISS) classification into the Giessen Hospital Information System WING.
  • To describe the expansion of TISS documentation across multiple intensive care and monitoring units.
  • To analyze the experiences and outcomes of implementing a comprehensive TISS documentation system.

Main Methods:

  • Integration of new functionalities into the existing WING system.

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  • Phased rollout across six intensive care units and three intensive monitoring units (109 beds total).
  • Utilized various front-end applications for data entry and documentation.

    • Main Results:

    • Complete TISS data documented for over a year, with an average of 14 interventions per patient per day.
    • Accumulated database exceeding one million entries.
    • Successful implementation without significant financial or manpower investment, utilizing existing hospital information systems.

    Conclusions:

    • TISS documentation is now a routine practice in all intensive care units at Giessen University hospital.
    • The system raised nurses' awareness of their activities, fostering interest in electronic care documentation.
    • Future goal is to extend intervention-based documentation to general wards, advancing electronic patient records.