Computerized documentation for a rural nursing intervention project.

Abstract

The Rural Partnership Linkage for Cancer Care project is a program of advanced practice nursing care made available to rural cancer patients to provide education, symptom management, referral, and support within their communities. The advanced practice nurses used a computerized clinical information system (CCIS) to record care. In this article the CCIS is described, the software and hardware requirements are discussed, and the outcomes and value of the system are discussed. The CCIS is a relational database run on laptop computers that includes screens for standard recording of demographics, physical exam, symptoms, and treatments. The advanced practice nurses track patient symptoms over time, noting which treatments are successful in resolving or reducing the problems. Information from patient visits is selected by help menus for inclusion into referral forms, reports of patient care, and discharge summaries. Reports can be faxed or mailed to distant sites. The research team uses the combined data set to examine symptom patterns, nursing diagnosis, and treatments that result in improved physical and psychological functioning and symptom resolution. Rural cancer patients and their families benefit from care management, participation in research, and communication of patient health status in an integrated and timely fashion made possible by the CCIS.