Documentation of Nursing Practice Using a Computerized Medical Information System

  • Carol Romano
Part of the Computers and Medicine book series (C+M)


As nursing practice expands in response to American Nurses Association and Joint Commission on Accreditation standards and Nurse Practice Acts, so too does the recording of nursing care increase in complexity. Expanded practice demands more documentation of care because legally and professionally, the nursing care documented is defined as the nursing care given.1 The increased utilization of computer technology in managing the complexity of nursing documentation is unquestioned.2 The use of computers, however, heralds the need to define the nursing data base content needed to assess, plan, implement, and evaluate patient care. This paper describes the nursing content framework that has been developed using parameters consistent with the Technicon Medical Information System. This hospital-wide computerized system is used at the Clinical Center, the research hospital of the National Institutes of Health (NIH) in Bethesda, Maryland.


Nursing Care Nurse Practice Medical Order Lung Sound Accreditation Standard 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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Copyright information

© IEEE 1981

Authors and Affiliations

  • Carol Romano

There are no affiliations available

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