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Documentation of Nursing Practice Using a Computerized Medical Information System

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

Abstract

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.

Keywords

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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References

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    Lesnik, M.J. and B.E. Anderson, Nursing Practice and the Law, Second edition, Philadelphia: J.B. Lippincott Co., 1955.Google Scholar
  2. Zielstorff, Rita Deziel, “The Planning and Evaluation of Automated Systems: A Nurse’s Point of View.”, Journal of Nursing Administration, July–August 1975, 22–25.Google Scholar
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    Henderson, Virginia, The Nature of Nursing, London, The Macmillan Co., 1972, p. 15.Google Scholar
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    Henderson, Virginia, The Nature of Nursing, London, The Macmillan Co., 1972, p. 15.Google Scholar
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    Maslow, Abraham Harold, Motivation and Personality, Second edition, New York, Harper and Row, 1970.Google Scholar
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    Kraegel, Janet, et al., Patient Care Systems, J.B. Lippincott Co., Philadelphia, 1974.Google Scholar
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    Gordon, Marjory, “Nursing Diagnosis and the Diagnostic Process”, American Journal of Nursing, 1976, Vol. 76 No. 8, 1298–1300.Google Scholar

Copyright information

© IEEE 1981

Authors and Affiliations

  • Carol Romano

There are no affiliations available

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