By Clement J. McDonald (auth.), Marion J. Ball Ed.D., Morris F. Collen (eds.)

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Extra info for Aspects of the Computer-based Patient Record

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Can a revised. twenty-first century medical record be used as a toolfor paring costs. monitoring physicians. andlength of stayanalysis? Whyshouldn't a hospital beinterested in suchtools? Currentmedical records systems coupledwithexisting utilization reviewsystems providesufficient dataforall hospital administrators and physicians to identify which physicians consume patientdaysandorderprocedures that are beyond normal practice patterns. Although some systems are far more sophisticated than others, the basic information that enables discover of those clinicians and quantification of the excesses existspresently.

The average nurse mustretain far morethanthis volumeof information in short-term memory. The system that can function as a powerful memory support tool for the nurse will enhance productivity and the quality of nursingcare. System Security and Data Integrity Considerations The system must provideadequateprotectionagainst unauthorized data access. this will include both departmental and personal ID codes. Both are necessary to gain access to any part of the system. Alternatively. ) may be used to give authorizedusers accessand to bar access to all others.

For example,the system shouldpermitthe nursing department to extract data from the patient record to enter into its patient classification system, or to a consortium database. • The systemshouldeasilyacceptdata entryfrom electronic monitoring devices and equipment in the patient care area. For example, physiologic monitors shouldbe able to directly recordinformation into the automated patientrecord rather than forcing the nurse to copy that information from one computer to another. • The system should be a part of an integrated patientcare system.

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