III. the Physicians Office and Group Practice—Ambulatory Medical Record Systems: B. Entering Medical Data into Automated Systems: The Computerized Notation System A Portable Self-Contained System for Entry of Physicians and Nurses Notes

摘要

The Computerized Notation System (CNS) is a portable microprocessor system designed for use in both outpatient clinics, hospital wards, and intensive care units. It can produce essentially all written communication required of both physicians and nurses, with printout at the bedside or in the clinic examining room. It is designed to ameliorate several problems which have limited direct computer entry by physicians and nurses (keyboard and processor access, marginal typing skills, lack of immediate printout, and logical restrictions of menu choices). The system encourages and simplifies use of the problem-oriented approach to the patient, by producing organized, legible daily notes and patient summaries. Printouts of the system are compatible with the present hospital and clinic “paper charts”. Clinical trials have confirmed the applicability, variability, and acceptance of the CNS in both hospital and outpatient practice.