Comprehensive computerized neonatal intensive care unit data system including real-time, computer-generated daily progress notes.

Abstract

A neonatal intensive care unit patient data system, NeoData, which was developed using microcomputers connected by a local area network, is described. The system allows for real-time generation of daily progress notes, as well as admission and discharge summaries. It includes two databases: one for daily patient data and one for admission/discharge summary data. Both sets of data are easily accessible for later analysis and report generation. The daily patient data are entered directly into a computer by the neonatal intensive care unit medical and nurse practitioner staff; a progress note is printed immediately thereafter for inclusion in the patient's chart. Data from the previous day are selectively carried forward into the current day's note, minimizing data entry. Several benefits are derived from this progress note system, including legibility, tracking of laboratory and other data, tracking of management plans and procedures due at a later date, and significant time savings. The system has proved to be easy to learn, and the neonatal intensive care unit staff have found it to contribute to the efficient delivery of patient care.