T. Burkle et al., COMPUTER-BASED NURSING DOCUMENTATION MEANS TO ACHIEVE THE GOAL, International journal of medical informatics, 52(1-3), 1998, pp. 71-80
Citations number
25
Categorie Soggetti
Computer Science Information Systems","Medical Informatics","Computer Science Information Systems
New functions have been integrated in the Giessen Hospital Information
System WING to support the classification of all intensive care patie
nts into the Therapeutic Intervention Scoring System (TISS). The use o
f those functions has been pushed when health insurance bodies demande
d evidence for the correct classification of ICU beds. This article pr
esents an overview on this development from the start in just one inte
nsive care unit to the complete coverage of six intensive care units a
nd three intensive monitoring units with a total of 109 beds. For thos
e units complete TISS data has been documented for more than a year no
w at a detailed level. On average 14 interventions have been recorded
per patient and day, accumulating to a database with more than a milli
on entries. We describe the experiences made during introduction and t
he different front-end applications we used to achieve the goal. Resul
ts gained from the huge database and their implications for our future
work are discussed. TISS documentation is now an established routine
on every intensive care unit of our University hospital. It has been i
mplemented without major financial or manpower investments and no spec
ific intensive care information system has been needed. Establishing t
his type of basic care documentation made nurses aware of their activi
ties, so that now they consider electronic care documentation to be in
their very own interest. The next goal has been set by nurses themsel
ves, they want to establish intervention based care documentation on n
ormal wards as well. We think that step by step we will thus be able t
o achieve a more complete electronic patient record. (C) 1998 Elsevier
Science Ireland Ltd. All rights reserved.