作者: Melody J. Ritter , James R. Douglas
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摘要: During the administration of anesthesia, anesthesia provider has historically created a paper record, charted manually, that included extensive patient care-related data (vital signs, other parameters, etc) and commentaries. DocuSys, proprietary information management system (AIMS), creates an electronic version record provides additional information. It electronically captures from clinical monitors sources, including scheduling applications laboratory computers. The AIMS facilitates chart entries such as drug doses case narratives. Benefits include improved legibility greater efficiency in documentation efforts. Use assists practitioner with decision support logic, timing antibiotic inclusion legally required documentation. Upon completion, are immediately available to systems, billing medical records. Data can be made single or, more important, thousands cases analyze variables services, adherence best practices, outcomes, research. was deployed at main campus Ochsner Health System on March 26, 2009. In this article, we discuss issues involved implementation process: successes, surprises, continued challenges.