Data Acquisition and the Computer-based Patient Record
Consideration of data acquisition for the computer-based patient record (CPR) should be accompanied by general understanding of the scope, intended contents and function of the patient record. The medical record serves as an active component of the ongoing care process. It contains information on the origins, progress and outcome of a patient’s disease(s) so that optimal care can be provided for the patient over an extended period of time. It contains documentation from all relevant sources. Coupled with medical knowledge bases and appropriate programs for medical inference, the data in the patient record serves as a decision support aid and as a pointer to medical literature (McDonald and Tierney 1986).
KeywordsData Entry Free Text Nursing Unit Laboratory Information System Medical Knowledge Base
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