Knowledge enabled plan of care and documentation prototype.
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.
DaDamio
Rebecca
R
Siemens Medical Solutions-Health Services Corp., Malvern, Pennsylvania, USA.
Gugerty
Brian
B
Kennedy
Rosemary
R
D004282:Documentation; D010347:Patient Care Planning; D019095:Point-of-Care Systems; D012984:Software; D014481:United States