The PEN&PAD model for clinical record systems has been successfully used for medical records in both General Practice and hospital-based care. This paper describes experiences of using the model for developing computer-based nursing records. Results from this work 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.
|Title of host publication||Proceedings of the Annual Symposium on Computer Application in Medical Care|
|Editors||Judy G. Ozbolt|
|Publisher||American Medical Informatics Association|
|Number of pages||6|
|Publication status||Published - 1994|
|Event||Eighteenth Annual Symposium on Computer Applications in Medical Care - Sheraton Washington Hotel, Washington, United States|
Duration: 5 Nov 1994 → 9 Nov 1994
Conference number: 18
|Conference||Eighteenth Annual Symposium on Computer Applications in Medical Care|
|Period||5/11/94 → 9/11/94|
Heathfield, HA., Hardiker, NR., & Kirby, J. (1994). Using the PENPAD information model to support hospital-based clinical care. In J. G. Ozbolt (Ed.), Proceedings of the Annual Symposium on Computer Application in Medical Care (pp. 452-456). American Medical Informatics Association.