South Dakota State University Open PRAIRIE: Open Public Research Access Institutional Repository and Information Exchange College of Nursing Faculty Publications College of Nursing 1995 Computerized Patient Records and NP Practice. Polly A. Hulme South Dakota State University, [email protected] Follow this and additional works at: http://openprairie.sdstate.edu/con_pubs Part of the Health Information Technology Commons, and the Nursing Commons Recommended Citation Hulme, Polly A., "Computerized Patient Records and NP Practice." (1995). College of Nursing Faculty Publications. 56. http://openprairie.sdstate.edu/con_pubs/56 This Article is brought to you for free and open access by the College of Nursing at Open PRAIRIE: Open Public Research Access Institutional Repository and Information Exchange. It has been accepted for inclusion in College of Nursing Faculty Publications by an authorized administrator of Open PRAIRIE: Open Public Research Access Institutional Repository and Information Exchange. For more information, please contact [email protected]. NPnews Computerized Patient Records and NP Practice Computer-based patient records in; the entry is then automatically coded the user as information. There are sev­ (CPRs) are becoming increasingly com­ for storage. Coded data save storage eral levels of information systems used mon in ambulatory settings. The advan­ space and render the data ready for in health care. At the patient level are tages of computer-based patient re­ statistical analysis. clinical information systems. The CPR is cords over paper records are multiple: Data can also be entered using free a clinical information system, because it they save space and time, help health text. Free text is the usual mode of aids in the management and documen­ care providers improve patient care, organizing data for providers. However, tation of patient care. At the administra­ and provide clinical and managerial the major disadvantage of free text is the tive level, management information sys­ information quickly. Currently, however, difficulty of retrieving data across re­ tems help administrators manage the this software is based on the medical cords. Although some free text is una­ delivery of health care. Quality assess­ model. voidable, a CPR completely in free text ment and improvement (QAI) programs The software for computer-based is merely an "electronic piece of paper" are an example of the use of this type of patient records was developed about with little improvement over the paper information. Good CPR software will 25 years ago in academic health care record. In contrast, CPRs that have at elicit data for both clinical and manage­ settings, but was never disseminated least some structure have numerous ment information systems. Research extensively into other types of ambula­ advantages over paper records. can be conducted using information tory settings. Now, however, with the from either level. advent of more powerful personal com­ Advantages of CPRs Clinical information systems can be puters (PCs), this innovation is commer­ There are four major advantages of further divided into hospital and ambu­ cially available for smaller ambulatory CPRs: they save space, save time, latory systems. Nursing information sys­ practices. improve patient care, and serve as tems, which help nurses manage and While advanced practice nurses information systems. A single hard disk document patient care, are increasingly (APNs) can use this software as readily holds thousands of records and takes evident in hospital systems, but not so in as physicians, they also have a perfect up only a few inches of space. The ambulatory systems. The absence of opportunity to add the nursing data that tapes used for daily backup take up nursing information in ambulatory clini­ differentiate their practices from that of about the same amount of space. cal information systems is particularly physicians. The addition of standard­ Time can be saved in many ways. detrimental for APNs during periods of ized nursing data to computer-based For example, completed encounter potential health care reform, since infor­ patient record software would help forms, physical examinations, and other mation from aggregated information APNs integrate nursing diagnoses, in­ customized reports can be quickly gen­ systems is what often drives public terventions, and outcomes into their erated, as well as flow sheets or labora­ policy at the local, state, and federal management plan; and facilitate re­ tory reports. Telephone consultations levels. With the increasing use of CPRs search on advanced practice nursing. can be done instantaneously since the in ambulatory settings, however, APNs Software vendors need to be encour­ provider always has the chart on hand. have an ideal chance to document the aged to fully integrate standardized Workstations in multiple sites, including advanced nursing care they provide nursing data into CPR software so APNs the examining rooms, allow instant re­ patients. can fully document their practice, im­ trieval and entry into patient records. Examples of CPR Software prove patient care, and facilitate nursing Some programs will automatically place research. a prescription on the medication list, The earliest CPRs were developed progress note, and on the prescription almost 25 years ago in academic cen­ Improved Capabilities blank itself with only one entry. Key word ters, but their dissemination to ambula­ Most CPR software programs use a searches can be used to find notes on tory settings outside large health main­ database format to collect the data into an old problem. And at least one piece tenance organizations (HMOs) and aca­ files and a database management sys­ of available software allows patients to demic settings has been disappoint­ tem to manage and access the data. type their own health histories into the ingly slow. Three well known early sys­ The more powerful PCs allow the stor­ computer using a multiple choice for­ tems still in use are the Computer Stored age and management of the large mat. The computer then assimilates the Ambulatory Records System (COSTAR) IISIrn"ll",ta nf nato nAAn,al"'l fnr ~cn:::Ia l"'4ata. ''''tl''\ a ru:t.rra,tl\JA fnr", that "an n.c. rtAvAlnnArt At HArvArd LJnlvAnlitv. ThA ..' ,...... ""',.,,,'" ....,. '''' 1o/"""10''''.'"IJ._''' I VI .""'1,.,"-, "'..".,,.,,.,.'" •. I"'VWI I ~"'m'., n••nn car. ~n~rm, .,nc. ,mor" patient record software would help forms, physical examinations, and other matlon from aggregated information APNs integrate nursing diagnoses, in­ customized reports can be quickly gen­ systems is what often drives public terventions, and outcomes into their erated, as well as flow sheets or labora­ policy at the local, state, and federal management plan; and facilitate re­ tory reports. Telephone consultations levels. With the increasing use of CPRs search on advanced practice nursing. can be done instantaneously since the in ambulatory settings, however, APNs Software vendors need to be encour­ provider always has the chart on hand. have an ideal chance to document the aged to fully integrate standardized Workstations in multiple sites, including advanced nursing care they provide nursing data into CPR software so APNs the examining rooms, allow instant re­ patients. can fully document their practice, im­ trieval and entry into patient records. prove patient care, and facilitate nursing Some programs will automatically place Example. of CPR Software research. a prescription on the medication list, The earliest CPRs were developed progress note, and on the prescription almost 25 years ago in academic cen­ Improved Capabilities blank itself with only one entry. Key word ters, but their dissemination to ambula­ Most CPR software programs use a searches can be used to find notes on tory settings outside large health main­ database format to collect the data into an old problem. And at least one piece tenance organizations (HMOs) and aca­ files and a database management sys­ of available software allows patients to demic settings has been disappoint­ tem to manage and access the data. type their own health histories into the ingly slow. Three well known early sys­ The more powerful PCs allow the stor­ computer using a multiple choice for­ tems still in use are the Computer Stored age and management of the large mat. The computer then assimilates the Ambulatory Records System (COSTAR) amounts of data needed for CPRs, data into a narrative form that can be developed at Harvard University, The allowing smaller practices to take ad­ reviewed and corrected with the patient. Medical Record (TMR) developed at vantage of the software technology. CPRs can improve patient care in Duke University, and the Regenstrief Another technological advance is multiple ways. For example, individual­ Medical Information System (RMIS) local area network (LAN) software, ized patient instruction sheets, reports devloped at the University of Indiana. which electronically links a number of on delinquent tests for the entire prac­ The RMIS, which is the least wide­ computers to the PC with the CPR tice, and family linked medical records spread, was one of the first programs to software and data (called the "file­ can all aid in providing better patient include a computerized medical knowl­ server"). Thus, multiple users in a prac­ care. Before consulting with a patient, edge base. tice setting can share data, software, the provider can reformat information A new program, the Intelligent Medi­ and