The PEN & PAD Medical Record Model: Development of a Nursing Record for Hospital-based Care of the Elderly

Abstract:

The PEN & PAD Medical Record model describes a framework for an information model, designed to meet the requirements of an electronic medical record. This model has been successfully tested in a computer-based record system for General Practitioners as part of the PEN & PAD (GP) Project.

Experiences of using the model for developing computer-based nursing records are reported. Results show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient’s care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work has highlighted the need for nurses to clarify and make explicit their uses of information, and also provided them with some tools to assist in this task.

Keywords:

Medical Record - Nursing Record - Hospital-based Care - Clinical Systems - Knowledge Representation - Data Entry

Publikationsverlauf

Artikel online veröffentlicht:
12. Februar 2018

• REFERENCES

• 1 Howkins TJ, Kay S, Rector AL. et al. An overview of the PEN & PAD project. In: MIE 90; Lecture Notes in Medical Informatics. . Berlin: Springer-Verlag; 1990: 73-8.
• 2 Rector AL, Nowlan WA, Kay S. Foundations of an electronic medical record. Meth Inform Med 1991; 30: 179-86.
• 3 Rector AL, Nowlan WA, Kay S, Goble CA, Howkins TJ. A framework for modelling the electronic medical record. Meth Inform Med 1993; 32: 109-19.
• 4 Nowlan A, Rector A. Medical knowledge representation and predictive data entry. In: Stefanelli M, Hasman A, Fieschi M, Talmon J. eds. Lecture Notes in Medical Informatics. . Berlin: Springer-Verlag; 1991: 105-6.
• 5 GALEN. General Architecture for Language, Encyclopaedias and Nomenclatures in Medicine. Project 2012, AIM Initiative, EC. Technical Annex. 1994
• 6 Heathfield HA, Kirby J, Nowlan A, Rector A. PEN & PAD (Geriatrics): A collaborative patient record for the shared care of the elderly. In: Proceedings of the 16th Annual Symposium on Computer Applications in Medical Care. . New York: IEEE Computer Society Press; 1992: 147-50.
• 7 Rector AL, Horan B, Fitter M. et al. User centred design development of a general practice medical workstation: the PEN & PAX) experience. In: Proceedings of CHI ‘92. . Addison-Wesley: 1992: 932-6.
• 8 Kirby J, Heathfield HA. Analysis and design techniques for user centred design. In: Conference on Human Factors in Computing Systems CHI ‘93 and INTERACT ‘93, . 1993: 261-3.
• 9 Nygren E, Henriksson P. Reading the medical record. I. Comput Meth Progr Biomed 1992; 39: 1-12.
• 10 Niinimaki T, Poutanen H, Myllyla B-M, Tervopellikka R. Computers on the ward: orthopaedic care with a paperless medical record and nursing plan. In: Barber B, Cao D, Qin D, Wagner G. eds. MEDINFO 89. . Amsterdam: North-Holland Publ Comp; 1989: 818-21.
• 11 Baud R, Wagner J, Scherrer JR. Towards knowledge-based medical records. In: Reichertz PL, Lindberg DAB. eds. Lecture Notes in Medical Informatics. . Heidelberg: Springer-Verlag; 1988: 680-4.
• 12 Nygren E, Johnson M, Henriksson P. Reading the medical record. II. Comput Meth Progr Biomed 1992; 39: 13-25.
• 13 Dick RS, Steen EB. eds. The Computer-based Patient Record An Essential Technology for Health Care. Committee on Improving the Patient Record, Division of the Health Care Services, Institute of Medicine. Washington DC: National Academy Press; 1991
• 14 Benoit R, Canfield K, Teitelbaum S. et al. Frame-based clinical data entry: Design issues for physician acceptance. In: Lun KC, Degoulet P, Piemme TE, Rienhoff O. eds. MEDINFO 92. . Amsterdam: Elsevier Science Publ; 1992: 1280-5.
• 15 Bell DS, Greenes RA, Doubilet P. Form-based clinical input from a structured vocabulary: Initial application in ultrasound reporting. In: Proceedings of the 16th Annual Symposium on Computer Applications in Medical Care. . New York: IEEE Computer Society Press; 1992: 789-90.
• 16 Assimacopoulos A, Borgazzi A. An electronic patient record combining free text and coded nomenclature: Application to nursing process. In: Lun KC, Degoulet P, Piemme TE, Rienhoff O. eds. MEDINFO 92. . Amsterdam: Elsevier Science Publ; 1992: 746-50.
• 17 Gouveia-Oliveira A, Salgado NC, Azevedo AP. et al. The architecture of SISCOPE. Designing a flexible, reusable clinical reporting system. In: Lun KC, Degoulet P, Piemme TE, Rienhoff O. eds. MEDINFO 92. . Amsterdam: Elsevier Science Publ; 1992: 402-7.
• 18 Heathfield HA, Kirby J, Nowlan A, Rector A. Requirements for an integrated patient record system for care of the elderly. In: MIE 1993. Lecture Notes in Medical Informatics. . Heidelberg: Springer-Verlag; 1993
• 19 Hardiker NR. Towards an information infrastructure for nursing: a critique of the nursing record. Information Technology in Nursing. 1994. 6.1: 7-9.
• 20 Dukes S, Copp G. Hidden nursing. Nursing Times 1992; 88: 40-2.
• 21 Chessare JB, Torok KE. Implementation of COSTAR in an academic group practice of general pediatrics. MD Computing 1993; 10: 23-7.
• 22 Van der Lei J, Duisterhout JS, Westerhof HP. et al. The introduction of computer-based patient records in The Netherlands. Ann Intern Med 1993; 119: 1036-41.
• 23 Heathfield HA, Wyatt J. Philosophies for the design and development of clinical decision-support systems. Meth Inform Med 1993; 32: 1-8.