The computerized medical record system: meeting the challenge for nursing

Abstract

A system of computerized medical record-keeping in a health maintenance organization is described. Some problems arising in the shift from manual to computerized record-keeping are discussed. Perhaps the most important for nursing is the increase in the nursing staff's responsibility for complete, consistent documentation of patient care concomitant with the shift to a computerized system. Nurses must be comfortable with patient assessment, patient management and documentation in order to utilize the system effectively.