Automated patient care documentation: what's in it for us? An expert system emergency drug card printout.
This article summarizes experiences to date for a collaborative approach, utilizing systems analysis and decision support methods, to design, develop, and implement automated patient centered documentation. Current manual methods for retrieving patient centered data for treatment activities and evaluation of practice are laborious, frustrating and often uneventful. Accessing specific patient information in an arrest or emergent situation, in the hospital and out patient clinical setting, is fraught with difficulties of data and information availability, reliability, legibility, integrity, security, and obsolescence. Treatment decisions made during an arrest or emergent situation, whether for an in-patient or clinical out patient, utilize Advanced Life Support guidelines and also may vary based on the heuristics of the lead practitioner on duty at the time. Walking the informatics talk of "managing and processing data to information to knowledge" lead to standardization for best practice of emergency drug calculations and treatments (1). An expedient and reliable method for retrieving patient specific data to calculate 26 medications, 3 treatments, and upwards of 40 criteria to consider during an arrest or emergent situation was achieved and implemented, as a by product of height and weight charting, across most all patient care areas at Primary Children's Medical Center in Salt Lake City Utah.
Bjornstad
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Primary Children's Medical Center, Salt Lake City, Utah, USA.
Farr
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Vernon
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Welkie
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Witte
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D001292:Attitude to Computers; D002648:Child; D004360:Drug Therapy, Computer-Assisted / Q000379:methods*; D005103:Expert Systems; D006801:Humans; D016247:Information Storage and Retrieval; D016347:Medical Records Systems, Computerized; D010347:Patient Care Planning