Microlevel documentation: relational database for critical path development.

Abstract

There have been great strides in developing hospital information systems (HISs); however, there are few if any systems that are fully integrated to allow nursing documentation at microlevel data--that is, information about interventions between a nurse or other health care disciplines and the patient. It consists of the data used by a nurse in taking care of patients at the intervention level. This article suggests a process for developing a fully integrated HIS that will build a nursing minimum data set (NMDS) to aid in case management systems development, costing-out services, and nursing research. The goal of the system is to decrease the amount of paperwork, allowing the nurse to spend more time with the patient, and at the same time improving the quality of documentation and improving patient outcomes.