title: Automated nursing documentation: a design perspective.
abstract: The concept of an automated nursing documentation system has been subject to casual debate for a number of years. During this time, Hewlett-Packard developed a system that is both adequate and workable from many perspectives (i.e. the Staff Notes Subsystem of the Patient Data Management System-PDMS). This package has been used as the primary method to document patient care for six years in the Critical Care Units of Phoenix Baptist Hospital. With the aid of Baptist Hospitals and Health Systems (BHHS) Design Engineers, it continues to evolve predicated on a singular intent: To provide the type of documentation required by the medical staff. The objective of this paper is multifold. Foremost, generalized criteria are established to provide a vehicle for standardizing the design or evolution of a staff notes package. The generic structure of the PDMS notes subsystem is discussed in regard to its parity with these criteria. Finally, custom modifications and additions to this package will be presented, and recommendations for future enhancements will be outlined.
mesh_terms: D003628:Database Management Systems / Q000592:standards; D005069:Evaluation Studies as Topic; D009737:Nursing Records / Q000592:standards; D012984:Software / Q000592:standards