By Clement J. McDonald (auth.), Marion J. Ball Ed.D., Morris F. Collen (eds.)
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Both are necessary to gain access to any part of the system. Alternatively. ) may be used to give authorizedusers accessand to bar access to all others. For example. ). Thisrequirement willnecessitate complexleveldefmitions, but may greatly add to the securityof the patientrecord. • Thepatientrecordmustbeprotectedagainstunauthorized accessthroughphone lines by persons who randomlyenter passwords in an effort to gain entry. For example, some systems automatically disconnect wheneverthe password has beenenteredtwiceincorrectly.
In both settings,thereare basically six categories of problems, in roughly increasing levels of sophistication: • • • • • • Symptoms Signs Abnormal laboratory data Pathophysiologic states Diagnoses Psychosocial problems However, anofficeproblem list is conveniently dividedintoan acuteanda chronic 14 User Needs for CPRs or recurrentproblemlist; in addition, a summary list of major problems, current medications, and recent visitsis useful. From the perspective of the practitioner, his or her need at the end of a hospitalization is for a complete problem list accompanied by discharge recommendations and medications.
1969. Medical Records, Medical Education. and PatientCare. Chicago: YearBook Medical Publishers, Inc. 3 Nurses' Needs for Computer-based Patient Records Mary L. McHugh Functional Specifications for an Automated Nursing Record Considerationsof System Design The system must fullyaccommodate the range and complexity of clinicalnursing data. • Nurses collecta large numberof distinctdata items. , multiple measurements of a patient's vital signs). • In manycases,repeatmeasures are performed in an essentially randomfashion.