Evaluating the impact of structured text and templates in ambulatory nursing.
This evaluation looks at the use of templates for entering structured text nursing notes that generate both a legal text note that is the chart record and an underlying coded form of the note to support analysis and research. This study reflects the first phase of a prototype project of an integrated, computerized health record. Templates are notes that have been prewritten using a standard clinical vocabulary. Templates can be used as the basis of a new clinical note and can be either signed unchanged or modified to represent variations in clinical presentation. The prototype setting is a Primary Care clinic where both physicians and nurses are using the computer to enter clinical notes. In the prototype clinic team, nursing utilized the CPR for 100% of all documentation from day one. Use of templates was found to be the most frequent method of initiating a note.
Crist-Grundman
D
D
Oceania Inc., Palo Alto, CA, USA.
Douglas
K
K
Kern
V
V
Gregory
J
J
Switzer
V
V
D004282:Documentation; D005069:Evaluation Studies as Topic; D006801:Humans; D016247:Information Storage and Retrieval; D016347:Medical Records Systems, Computerized; D009737:Nursing Records; D012984:Software; D014584:User-Computer Interface; D018875:Vocabulary, Controlled