Deane B. Taylor
Published: 1974
Total Pages: 176
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Professional nurses have long been identifying and interpreting clues related to the gathering of information from which such decisions could be consistently drawn. The organization, systematization, and clustering of such clues required an extensive search of what was meaningful to nurses in different clinical settings. The research staff who designed the project as a contract to fulfill some basic goals for collecting, disseminating and utilizing information data for patients' records, have spent 3 years refining an assessment tool with two major factors in mind. First, a guideline was needed to obtain the most accurate information possible about individual patients in the context of their families and the community. Second, an assessment tool was needed which was computer manageable in the sense that it could be adapted to an on-line system of computer input and retrieval which would supply significant information to multiple sources. Two major sets of assessment records have been developed from an exhaustive trial of forms in a variety of settings. Consultation has been obtained from resources country-wide to insure as broad a view as possible of the current efforts in the development of new record systems. Faculty, students and nursing service staff members in hospitals and community health agencies have participated in the trials of these forms in real situations.