| 摘要 |
A medical records software apparatus and method is described that allows a clinician, e.g., nurse or doctor, to combine entry of new patient orders, prescriptions, flowsheet observations, etc. into the documentation process or workflow. A documentation user interface is provided that pulls patient data from a database into the display. The user can select on the user interface a category of a patient record, e.g., Significant Events or Orders, view or edit prior entries in the database in these categories, and add additional documentation for that category. The documentation is written or pushed to two areas of the database, one devoted to patient documentation and a second area corresponding to the selected category, e.g., Orders. The method and apparatus improves workflow efficiency and promotes a smooth transition from the thought process of the clinician to the ordering or prescription process, without the need for changing venues or screen displays to both enter documentation and enter the order or new prescription. |
