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

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.

The nursing terminology summit: collaboration for progress

The Nursing Terminology Summit has used collaborative processes to bring about significant changes in the development of terminology standards for nursing. This paper draws on agendas, reports, notes, and other documents from the Summit, in addition to the authors' own experience as Organizer, Steering Committee, and participants, to provide a brief history of the Summit process. The analysis identifies factors that increased the risk of failure as well as factors that fostered success. The paper concludes with lessons learned that can be applied in other arenas to promote change in medical informatics.

Developing shared understanding through simulation

In this article relevant key findings of a review of selected published work are used to provide a foundation for a new approach to developing a shared understanding of aspects of health care delivery. The new approach makes use of simulation models. It is hoped that this approach will provide support for improved decision-making and for the development of more appropriate enabling tools.

A compositional approach to nursing terminology

The development of standardised vocabularies within nursing has been an important research activity for a number of years. Current representations generally take the form of taxonomic vocabularies. These are seen as important as they provide a structure for retrieving and analysing data from automated systems. However, there is increasing evidence to show that traditional taxonomic vocabularies are unsuitable for capturing detailed clinical data. This paper describes how GRAIL (GALEN Representation and Integration Language) is being used within the TELENURSE project to develop a representation of nursing terminology which is sufficiently expressive for documenting detailed clinical data while retaining the benefits of traditional taxonomic vocabularies.

The PEN & PAD medical record model: development of a nursing record for hospital-based care of the elderly

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 had 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.