Computer-based patient record systems.

Abstract

OBJECTIVES: To provide oncology nurses with an overview of computer-based patient record (CPR) systems, a key infrastructure requirement in information management that is essential to maintaining a scientific basis for health care. DATA SOURCES: Published articles, research studies, and review articles pertaining to CPR systems. CONCLUSIONS: Progress in hardware development, software applications, and interfaces combine to bring us multimedia patient record systems. Many obstacles have been overcome as standards have emerged and technologies conform to those standards. However, there has been limited success in implementation of such systems. Early acceptance of structured data and problem-oriented documentation set the framework for charting in the electronic record. IMPLICATIONS FOR NURSING PRACTICE: Oncology clinicians and cancer patients alike will realize greater efficiencies and increased quality in health care when the CPR is fully implemented.