Care planning as a strategy to manage variation in practice: from care plan to integrated person-based record.
This article begins with a summary of the trend toward a person-based health record, and the need to integrate data from a variety of sources to achieve this. A project is described that demonstrated problems with the structure of nursing care plans. These problems affected the ability to integrate care plan data into a clinical database capable of analysis to link control of process with clinical outcome. A second project is described that focused on the development of data sets holding higher-level descriptions suitable for the maintenance of a person-based record, but at a summarized level and with no clinical detail. Finally, a prototype care planning system is described that, while maintaining the data required by the Nursing Process, was more flexibly structured to support analysis and hierarchical levels of description.
Hoy
J D
JD
Health Systems Division, National Health Service in Scotland, Edinburgh, United Kingdom.
Hyslop
A Q
AQ
D003152:Community Health Nursing; D003198:Computer Simulation; D003626:Data Display; D006751:Hospital Information Systems / Q000458:organization & administration*; D006801:Humans; D016247:Information Storage and Retrieval; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D009720:Nurse Clinicians; D009730:Nursing Assessment; D010347:Patient Care Planning; D012606:Scotland; D018511:Systems Integration