A number of museums have developed computerized documentation systems, some on-line but others relying on machine-generated indexes, periodically updated, to meet most of their information requirements.
We speculate that the widespread use of computerized documentation systems giving better access to clinical data will improve clinician's ability to evaluate outcomes and improve care.
In a survey of physicians at medical centers using computerized documentation systems, over 90% of participants expressed the need for training and education on the responsible use of the copy-paste feature [ 15].
Findings also suggest that a computerized clinical documentation system that specifically tracks nursing practice is vital if nurses are to identify and eventually be reimbursed for client care specific to nursing practice.
In this study, selected data from an 11-year clinical data set are presented to show the scope of academic CNC nursing practice, describe client services and expanded nursing roles, show the use of a computerized clinical documentation system in tracking nursing practice, and assess the usefulness of the Lundeen conceptual model.
Intermittent laboratory data, medications, and nursing interventions were derived from the computerized nursing documentation system (CareVue, Philips, Amsterdam, The Netherlands) and integrated with continuous data.
During the study, participating physicians continued to follow their routine documentation procedures, recording all treatment relevant diagnoses and all prescriptions for each consecutive patient using their existing computerized patient documentation system.
Because some primary care physicians were not able to identify high utilizers using their particular computerized patient documentation system, patients could also be identified using charts or asking the patients themselves.
High utilizers of healthcare services were identified by staff members in each study practice using either their computerized patient documentation system or the questionnaire employed to screen patients for participation in the study.
