COMPUTER-BASED NURSING DOCUMENTATION MEANS TO ACHIEVE THE GOAL

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.