ABSTRACT
The PEN & PAD Medical Record model describes a framework for an information model, designed to meet the requirements of an electronic medical record. This model has been successfully tested in a computer-based record system for General Practitioners as part of the PEN & PAD (GP) Project. Experiences of using the model for developing computer-based nursing records are reported. Results show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient's care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work had highlighted the need for nurses to clarify and make explicit their uses of information, and also provided them with some tools to assist in this task.
