title: Knowledge enabled plan of care and documentation prototype.
abstract: There exist significant challenges in integrating the plan of care into documentation and point of care operational processes. A plan of care is often a static artifact that meets regulatory standards with limited influence on supporting goal-directed care delivery processes. Although this prototype is applicable to many clinical disciplines, we will highlight nursing processes in demonstrating a knowledge-driven computerized solution that fully integrates the plan of care within documentation. The knowledge-driven solution reflects evidenced-based practice; is an effective tool for managing problems, orders/interventions, and the patient's progress towards expected outcomes; meets regulatory standards; and drives quality and process improvement. The knowledge infrastructure consists of fully represented terminology, structured clinical expressions utilizing the controlled terminology and clinical knowledge representing evidence-based practice.
authors.affiliation: Siemens Medical Solutions-Health Services Corp., Malvern, Pennsylvania, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: DaDamio
authors.forename: Brian
authors.initials: B
authors.lastname: Gugerty
authors.forename: Rosemary
authors.initials: R
authors.lastname: Kennedy
mesh_terms: D004282:Documentation; D010347:Patient Care Planning; D019095:Point-of-Care Systems; D012984:Software; D014481:United States