RESUMO
The University of Iowa Hospitals and Clinics (UIHC) implemented an online documentation system for patient care orders in 1994-1996. Developed entirely in-house, the INFORMM NIS (Information Network for Online Retrieval & Medical Management Nursing Information System) features order-generated task lists, defaulted charting responses, computer-generated chart forms, and graphical data displays. To measure the impact of automation on user perceptions, and documentation compliance, completeness, time, and location, a team of nursing and information systems representatives captured data before and after implementation. Staff surveys show more positive user perceptions. Documentation results indicate increased compliance and completeness, and a decrease or no change in time. Online documentation occurs mainly at unit workstations.
Assuntos
Atitude do Pessoal de Saúde , Atitude Frente aos Computadores , Documentação/métodos , Registros de Enfermagem , Sistemas On-Line , Assistência ao Paciente , Sistemas Computacionais , Coleta de Dados , Sistemas de Informação Hospitalar , Humanos , Armazenamento e Recuperação da Informação , Enfermeiras e EnfermeirosRESUMO
At the University of Iowa Hospitals and Clinics (UIHC), the Standardized Nursing Languages (SNLs) of Nursing Interventions Classification (NIC) and Nursing-sensitive Outcomes Classification (NOC) are being implemented in on-line care planning and documentation. NIC and NOC are being integrated in the INFORMM NIS (Information Network For Retrieval & Medical Management Nursing Information System). The implementation process for SNLs includes six components: objectives, programming, database content, education, utilization, and evaluation. This process has been used successfully in NIC implementation and will be applied in NOC field testing.
