Patient Discharge Referral: Interdisciplinary Collaboration Colleen M. Prophet, M.A., R.N. Department of Nursing T-100 GH The University of Iowa Hospitals and Clinics 200 Hawkins Drive Iowa City, Iowa 52242 Telephone 319-3562267 FAX 319-356-4545 reflects an interdisciplinary, collaborative model of discharge planning.
ABSTRAC The INFORMM (Information Network For Online Retrieval & Medical Management) patient discharge referralform is interdisciplinary in scope. The initial automatedform, implemented on 41 general inpatient care units as of December, 1991, involved the collaboration ofthe departments of Nursing, Social Services, Medical Records, and Patient Registration. As development proceeds, it is expected that other clinical disciplines will contribute additional data and information to augment and complement the content of the patient discharge referralform.
THE UNiVERSiTY OF IOWA HOSPITAL AND CLENICS (UIHC) The UIHC is a 891-bed tertiary level health care facility. The most recent fiscal year-end data reveal 28,409 acute inpatient admissions, and 465,610 ambulatory care visits. On a daily basis, care is provided to more than 2,500 patients by a staff of more than 7,560 members. Currently, the UIHC Department of Nursing consists of approximately 1,500 registered nurses, 55 clinical nursing specialists, 80 licensed practical nurses and 330 nursing assistants.
IWTRODUCTON
At UIHC, INFORMM contains 125 PCS/ADS system applications and operates on a IBM 3090-500J with a locally distributed network of 1,100 cathode ray terminals (CRTs), 200 personal computers (PCs), and 200 terminal printers. In order to produce chart-quality forms, IBM 3812 page printers were installed on the inpatient care units. Data on all UIHC patients are contained in a patient data base with 126 billion characters of online storage.
The American Nurses' Association (ANA) encourages nurses to respond to society's concerns, including new knowledge and technology, and specifically supports nurses in the development of Nursing Information Systems (NISs) [3,2]. In terms of patient discharge planning, the ANA asserts that professional nurses are accountable to plan for the continuity of care and cannot delegate this responsibility [1]. While patient discharge planning is clearly a responsibility of the registered nurse, many other health care disciplines are also accountable for the effectiveness of the discharge care plan. As noted by Romano, discharge planning requires a systematic, interdisciplinary approach to coordinate patient needs with available resources [5].
INFORMM NURSING INFORMATION SYSTEM The INFORMM NIS provides interdisciplinary communication and individualized care plans based upon current standards of care [7]. The care planning component of the NIS encompasses patient critical data, patient care orders, and patient problems/nursing diagnoses. As a system by-product, care planning generates and calculates patient acuity immediately for online review. The nursing data base, maintained by user personnel, contains content specific to patient populations, patient care units, and therapeutic modalities.
Furthermore, government regulations and standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require ongoing mechanisms to facilitate patient discharge planning [4]. While multiple models of discharge planning are used to ensure continuity of care, collaborative models, particularly involving registered nurses and social workers, often enhance the discharge planning process through synergistic team work [6]. At the University of Iowa Hospitals and Clinics (UIHC), the INFORMM patient discharge referral form
0195-4210/92/$5.00 ©)1993 AMIA, Inc.
332
nursing information on the discharge care plan
Designed entirely in house at UIHC, INFORMM NIS is being developed and implemented in three phases. In Phase I, Patient Care Planning was installed on 41 general inpatient care units in 1988; enhancements and implementation on critical care units are planned. Currently, Phase II: Patient Care Documentation is being established on the same general inpatient care units. At this time, two chart forms--the patient problem/nursing diagnosis form and the patient discharge referral form--are being produced. During Phase Ill, Patient Care Planning and Documentation will be installed on the ambulatory care units.
5) to capture patient discharge data for quality improvement, clinical and administrative research
PATIENT DISCHARGE REFERRAL: INTERDISCIPIARY DEVELOPMET The development process for the automated patient discharge referral form involves several hospital departments. While the long range goal is the establishment of an automated interdisciplinary patient discharge referral form, most clinical departments, at the onset of the project, had not developed any specific automated systems. In contrast, the INFORMM NIS was well established and in use for several years. For these reasons, it was decided to proceed with the development of the interdisciplinary form in a dynamic fashion; that is, the development, coordination, and implementation of each department's discharge content and supporting functions, one discipline at a time, beginning with nursing.
INFORMM NIS involves more than 2,350 nursing users and accounts for approximately 50,000 transactions daily. Of these transaction totals, a daily average of 8,000 relate to problem/nursing diagnosis functions which are available to nearly 1,000 registered nurses. The patient discharge referral functions, accessible to 1,200 nursing staff, generate approximately 3,000 transactions per day. On average, 300 problem/nursing diagnosis forms and 230 patient discharge referral forms are printed daily.
PATIENT DISCHARGE REFERRAL: OBJECTIVES
With the commitment to phased development and implementation of the interdisciplinary patient discharge referral form, the departments of Social Services, Medical Records, and Patient Registration collaborated with Nursing in the initial development of the form and associated functions. Each of these departments contributes and/or receives data related to the patient discharge referral form.
The objectives for the patient discharge referral form were:
1) to facilitate continuity of care by means of enhanced communication of patient data and nursing information to receiving facilities and agencies
In Social Services, social workers enter and verify facility data indicating arrangements confirmed by the patient, family, local physician, and receiving facility, e.g., nursing facility. In similar functions, registered nurses confirm agency data when the patient is being referred to an agency, e.g., visiting nurse. These facility and agency data trigger discharge dispositions that are automatically transmitted at patient discharge to the online medical record abstract, replacing activity formerly completed by coders in the Medical Records department.
2) to initiate an
interdisciplinary, computergenerated record of the discharge care plan for the patient chart and receiving facilities and agencies 3) to enhance efficiency and reduce redundancy in documentation by retrieving patient data and nursing information entered on the care planning and other system applications
The Patient Registration department, with Census and Visit systems, contributes patient demographic data, hospital stay information, and future appointments to the patient discharge referral form. Additionally, as part of discharge data collection,
4) to provide standardization in the required patient data and
333
nursing staff identify projected transportation at discharge. Since UIHC serves patients from a large geographic area, the office of Patient Transportation in Patient Registration offers 'hospital car' transportation to and from the hospital. Major enhancements were made to the online mechanisms for requesting and acknowledging these patient discharge transportation arrangements.
PATENT D SYS1
one-hour online demonstration and a one and one-half hour training session.
PATIENT DISCHARGE REFERRAL: FEATURES The INFORMM patient discharge referral form offers the features of a health care agency data base, an interdisciplinary message system, dynamic allocation of functions, and two print formats.
RGE REFERRAL:
M DEVELOPMENT
Health Cae Agency Data Base As with all computer applications, the initial step of the process was the examination of the existing manual process and forms. While many UIHC health care team members separately prepare and send information, registered nurses and social workers were able to document on a shared manual chart form. With the implementation of the automated form, Social Services decided to record their information on a manual chart form while social workers design their online functions and content.
In order to provide selections of facilities and agencies for the nurses and social workers, a directory of health care facilities and agencies was created. Maintained by user personnel, this data base currently contains approximately 3,000 entries of facilities and agencies sorted by county, state, and country. All authorized users in multiple departments have access to display this extensive data base of patient care resources.
Inerdisciplinary Message Sst
Following manual system review, a system logical design was proposed and approved by users and administrators in the involved departments. The project team then presented a simulation of online functions and draft forms for critique by multiple users. After revisions were incorporated, programming was created and fully tested prior to pilot.
Reflecting the interdisciplinary nature of discharge planning, the computerized system provides automatic messages to various departments. For example, if a nursing staff member overrides the facility data verified by a social worker, an immediate message is sent to Social Services. Similarly, if the registered nurse attempts to print a final copy and the facility data have not been verified by the social worker, a message is printed immediately in Social Services. In addition to receiving all requests for patient transportation by 'hospital car", the Patient Transportation office is immediately notified of changes in patient location or discharge data.
PATIENT DICHARGE REFERRAL: IMPLEMENTATION Similar to system development, the pilot and implementation of the patient discharge referral form involved several departments, principally Social Services, Medical Records, and Nursing. Prior to the installation of the nursing functions, social worker functions were activated in order to test both the functions and the interface with the patient's medical record abstract. Social workers were provided a one-half hour training session presented by a systems trainer.
The patient discharge referral form provides dynamic allocation of functions and printing. After patient admission, the nursing user may add/update data in any sequence. Although each form requires at least two pages, the length of the form is entirely dependent upon the discharge data entered for the particular patient. The front sheet of the patient discharge referral form contains standard data categories of agency information, patient information, hospital stay information, and patient critical data. The nursing information begins on page two with a list of patient problems/nursing
As occurred with the implementation of the care planning system, the patient discharge referral form was installed on the inpatient care units in three waves: a pilot on one unit, an expanded pilot on nine additional representative units, and finally, hospital-wide implementation on the remaining thirty-one units. Prior to system implementation on an inpatient care unit, nursing users were provided a
334
Domation Efficiency
diagnoses with associated etiologies and patient outcomes. Following this list, the patient discharge care orders are printed. Finally, the free-text categories of medications, discharge comments, and nursing care recommendations provide additional information.
Prin
Patient data and nursing information required for the patient discharge referral form may be found in care planning and/or discharge referral functions. In order to increase user ease, any shared data item modified in one function is simultaneously updated in any other location, and some patient data, such as future appointments, are automatically printed on the patient discharge referral form. When the discharge care plan changes, the registered nurse merely updates the information online in contrast to the manual method of rewriting the entire form.
Formas
For the patient discharge referral form, two print formats are available: working copy and final copy. Since discharge planning begins at the time of admission, working copies of the patient discharge referral may be printed on demand throughout the patient's hospitalization. However, at the time of discharge, the registered nurse prints at least two final copies: one for the patient chart and one for each receiving facility or agency. Furthermore, nurses on inpatient or ambulatory care units may print working copies up to six weeks post-discharge for follow-up patient care.
Content Standardization In preparation for the automation of the patient discharge referral form, unit nurses developed content specific to the discharge care plan, especially discharge protocols designed for patient populations. Although developed by particular patient care units, discharge protocols are available to all nurses, thereby providing shared nursing expertise and decision support. Moreover, all required data on the form must be entered to enable printing of the final
PATIENT DISCHIARGE REFERRAL: EVALUATION OF OBJECTIVES ACHIEVEMEN
copy.
The automated patient discharge referral form has achieved its stated objectives, and the response from both senders and recipients has been positive.
Quality Improvanent and Reearch The capabilities to store and retrieve discharge data are identical to care planning data. Patient and nursing data and information entered in the discharge referral functions are retained online 42 days post-discharge, then transferred to an archival file.
Continuit of Car The patient discharge referral form enhances the continuity of care post-discharge as well as during the hospital stay. Facilities and agencies report that the referral consistently provides more complete data which are essential, clear, concise, and legible. The intricate messaging system afforded by the automated functions facilitates collaborative efforts to plan the patient's discharge.
With appropriate approvals, quality improvement studies and clinical and administrative research can be conducted on the active and archived data.
SUNMMARY The endeavor to produce an interdisciplinary application is a formidable undertaking. With the ultimate, shared goal of interdisciplinary documentation, the phased development and implementation of the patient discharge referral form has created achievable, measurable, and evaluated segments of the envisioned final product. Rather than create a priori the final version, each discipline benefits from the successes and revisions of other disciplines, avoids duplication, and concentrates efforts on specific clinical content. With the successful implementation of the patient discharge referral form by Nursing, other health care
nterdiplinar Car Pla At the present time, the patient discharge referral
form contains patient data and nursing information. Efforts are ongoing to define additional interdisciplinary content and functions to augment and complement the initial patient discharge referral form.
335
disciplines are encouraged to create complementary functions and content.
[4] Hartigan, E. (1987). Discharge planning: Identification of high-risk groups. Nursing Management. 18(12), 30-32.
Referm [1] American Nurses' Association. (1975). Continuity of care and discharge planning programs in institutions and community agencies. (Publication No. NP-49). Kansas City, Missouri: ANA.
[5] Romano, C. (1984). A
computerized approach to discharge care planning. Nursing Outlook. 3(1), 23-25.
[6] Society for Hospital Social Work Directors of the American Hospital Association (1991). Discharge planning update. 11(5), September-October. 1-14.
[2] American Nurses' Association. (1986). Development of computerized nursing information systems in nursing services. (Resolution No. 24). Kansas City, Missouri: ANA.
[7] Prophet, C. (1989). Patient care planning: an interdisciplinary approach. In Proceedings of the thirteenth annual symposium of computer applications in medical care (SCAMC) 823-826. Washington, D.C.:IEEE Computer Society Press.
[3] American Nurses' Association. (1980). Nursing: A social policy statement. Kansas City, Missouri: ANA.
336
ABSTRAC The INFORMM (Information Network For Online Retrieval & Medical Management) patient discharge referralform is interdisciplinary in scope. The initial automatedform, implemented on 41 general inpatient care units as of December, 1991, involved the collaboration ofthe departments of Nursing, Social Services, Medical Records, and Patient Registration. As development proceeds, it is expected that other clinical disciplines will contribute additional data and information to augment and complement the content of the patient discharge referralform.
THE UNiVERSiTY OF IOWA HOSPITAL AND CLENICS (UIHC) The UIHC is a 891-bed tertiary level health care facility. The most recent fiscal year-end data reveal 28,409 acute inpatient admissions, and 465,610 ambulatory care visits. On a daily basis, care is provided to more than 2,500 patients by a staff of more than 7,560 members. Currently, the UIHC Department of Nursing consists of approximately 1,500 registered nurses, 55 clinical nursing specialists, 80 licensed practical nurses and 330 nursing assistants.
IWTRODUCTON
At UIHC, INFORMM contains 125 PCS/ADS system applications and operates on a IBM 3090-500J with a locally distributed network of 1,100 cathode ray terminals (CRTs), 200 personal computers (PCs), and 200 terminal printers. In order to produce chart-quality forms, IBM 3812 page printers were installed on the inpatient care units. Data on all UIHC patients are contained in a patient data base with 126 billion characters of online storage.
The American Nurses' Association (ANA) encourages nurses to respond to society's concerns, including new knowledge and technology, and specifically supports nurses in the development of Nursing Information Systems (NISs) [3,2]. In terms of patient discharge planning, the ANA asserts that professional nurses are accountable to plan for the continuity of care and cannot delegate this responsibility [1]. While patient discharge planning is clearly a responsibility of the registered nurse, many other health care disciplines are also accountable for the effectiveness of the discharge care plan. As noted by Romano, discharge planning requires a systematic, interdisciplinary approach to coordinate patient needs with available resources [5].
INFORMM NURSING INFORMATION SYSTEM The INFORMM NIS provides interdisciplinary communication and individualized care plans based upon current standards of care [7]. The care planning component of the NIS encompasses patient critical data, patient care orders, and patient problems/nursing diagnoses. As a system by-product, care planning generates and calculates patient acuity immediately for online review. The nursing data base, maintained by user personnel, contains content specific to patient populations, patient care units, and therapeutic modalities.
Furthermore, government regulations and standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require ongoing mechanisms to facilitate patient discharge planning [4]. While multiple models of discharge planning are used to ensure continuity of care, collaborative models, particularly involving registered nurses and social workers, often enhance the discharge planning process through synergistic team work [6]. At the University of Iowa Hospitals and Clinics (UIHC), the INFORMM patient discharge referral form
0195-4210/92/$5.00 ©)1993 AMIA, Inc.
332
nursing information on the discharge care plan
Designed entirely in house at UIHC, INFORMM NIS is being developed and implemented in three phases. In Phase I, Patient Care Planning was installed on 41 general inpatient care units in 1988; enhancements and implementation on critical care units are planned. Currently, Phase II: Patient Care Documentation is being established on the same general inpatient care units. At this time, two chart forms--the patient problem/nursing diagnosis form and the patient discharge referral form--are being produced. During Phase Ill, Patient Care Planning and Documentation will be installed on the ambulatory care units.
5) to capture patient discharge data for quality improvement, clinical and administrative research
PATIENT DISCHARGE REFERRAL: INTERDISCIPIARY DEVELOPMET The development process for the automated patient discharge referral form involves several hospital departments. While the long range goal is the establishment of an automated interdisciplinary patient discharge referral form, most clinical departments, at the onset of the project, had not developed any specific automated systems. In contrast, the INFORMM NIS was well established and in use for several years. For these reasons, it was decided to proceed with the development of the interdisciplinary form in a dynamic fashion; that is, the development, coordination, and implementation of each department's discharge content and supporting functions, one discipline at a time, beginning with nursing.
INFORMM NIS involves more than 2,350 nursing users and accounts for approximately 50,000 transactions daily. Of these transaction totals, a daily average of 8,000 relate to problem/nursing diagnosis functions which are available to nearly 1,000 registered nurses. The patient discharge referral functions, accessible to 1,200 nursing staff, generate approximately 3,000 transactions per day. On average, 300 problem/nursing diagnosis forms and 230 patient discharge referral forms are printed daily.
PATIENT DISCHARGE REFERRAL: OBJECTIVES
With the commitment to phased development and implementation of the interdisciplinary patient discharge referral form, the departments of Social Services, Medical Records, and Patient Registration collaborated with Nursing in the initial development of the form and associated functions. Each of these departments contributes and/or receives data related to the patient discharge referral form.
The objectives for the patient discharge referral form were:
1) to facilitate continuity of care by means of enhanced communication of patient data and nursing information to receiving facilities and agencies
In Social Services, social workers enter and verify facility data indicating arrangements confirmed by the patient, family, local physician, and receiving facility, e.g., nursing facility. In similar functions, registered nurses confirm agency data when the patient is being referred to an agency, e.g., visiting nurse. These facility and agency data trigger discharge dispositions that are automatically transmitted at patient discharge to the online medical record abstract, replacing activity formerly completed by coders in the Medical Records department.
2) to initiate an
interdisciplinary, computergenerated record of the discharge care plan for the patient chart and receiving facilities and agencies 3) to enhance efficiency and reduce redundancy in documentation by retrieving patient data and nursing information entered on the care planning and other system applications
The Patient Registration department, with Census and Visit systems, contributes patient demographic data, hospital stay information, and future appointments to the patient discharge referral form. Additionally, as part of discharge data collection,
4) to provide standardization in the required patient data and
333
nursing staff identify projected transportation at discharge. Since UIHC serves patients from a large geographic area, the office of Patient Transportation in Patient Registration offers 'hospital car' transportation to and from the hospital. Major enhancements were made to the online mechanisms for requesting and acknowledging these patient discharge transportation arrangements.
PATENT D SYS1
one-hour online demonstration and a one and one-half hour training session.
PATIENT DISCHARGE REFERRAL: FEATURES The INFORMM patient discharge referral form offers the features of a health care agency data base, an interdisciplinary message system, dynamic allocation of functions, and two print formats.
RGE REFERRAL:
M DEVELOPMENT
Health Cae Agency Data Base As with all computer applications, the initial step of the process was the examination of the existing manual process and forms. While many UIHC health care team members separately prepare and send information, registered nurses and social workers were able to document on a shared manual chart form. With the implementation of the automated form, Social Services decided to record their information on a manual chart form while social workers design their online functions and content.
In order to provide selections of facilities and agencies for the nurses and social workers, a directory of health care facilities and agencies was created. Maintained by user personnel, this data base currently contains approximately 3,000 entries of facilities and agencies sorted by county, state, and country. All authorized users in multiple departments have access to display this extensive data base of patient care resources.
Inerdisciplinary Message Sst
Following manual system review, a system logical design was proposed and approved by users and administrators in the involved departments. The project team then presented a simulation of online functions and draft forms for critique by multiple users. After revisions were incorporated, programming was created and fully tested prior to pilot.
Reflecting the interdisciplinary nature of discharge planning, the computerized system provides automatic messages to various departments. For example, if a nursing staff member overrides the facility data verified by a social worker, an immediate message is sent to Social Services. Similarly, if the registered nurse attempts to print a final copy and the facility data have not been verified by the social worker, a message is printed immediately in Social Services. In addition to receiving all requests for patient transportation by 'hospital car", the Patient Transportation office is immediately notified of changes in patient location or discharge data.
PATIENT DICHARGE REFERRAL: IMPLEMENTATION Similar to system development, the pilot and implementation of the patient discharge referral form involved several departments, principally Social Services, Medical Records, and Nursing. Prior to the installation of the nursing functions, social worker functions were activated in order to test both the functions and the interface with the patient's medical record abstract. Social workers were provided a one-half hour training session presented by a systems trainer.
The patient discharge referral form provides dynamic allocation of functions and printing. After patient admission, the nursing user may add/update data in any sequence. Although each form requires at least two pages, the length of the form is entirely dependent upon the discharge data entered for the particular patient. The front sheet of the patient discharge referral form contains standard data categories of agency information, patient information, hospital stay information, and patient critical data. The nursing information begins on page two with a list of patient problems/nursing
As occurred with the implementation of the care planning system, the patient discharge referral form was installed on the inpatient care units in three waves: a pilot on one unit, an expanded pilot on nine additional representative units, and finally, hospital-wide implementation on the remaining thirty-one units. Prior to system implementation on an inpatient care unit, nursing users were provided a
334
Domation Efficiency
diagnoses with associated etiologies and patient outcomes. Following this list, the patient discharge care orders are printed. Finally, the free-text categories of medications, discharge comments, and nursing care recommendations provide additional information.
Prin
Patient data and nursing information required for the patient discharge referral form may be found in care planning and/or discharge referral functions. In order to increase user ease, any shared data item modified in one function is simultaneously updated in any other location, and some patient data, such as future appointments, are automatically printed on the patient discharge referral form. When the discharge care plan changes, the registered nurse merely updates the information online in contrast to the manual method of rewriting the entire form.
Formas
For the patient discharge referral form, two print formats are available: working copy and final copy. Since discharge planning begins at the time of admission, working copies of the patient discharge referral may be printed on demand throughout the patient's hospitalization. However, at the time of discharge, the registered nurse prints at least two final copies: one for the patient chart and one for each receiving facility or agency. Furthermore, nurses on inpatient or ambulatory care units may print working copies up to six weeks post-discharge for follow-up patient care.
Content Standardization In preparation for the automation of the patient discharge referral form, unit nurses developed content specific to the discharge care plan, especially discharge protocols designed for patient populations. Although developed by particular patient care units, discharge protocols are available to all nurses, thereby providing shared nursing expertise and decision support. Moreover, all required data on the form must be entered to enable printing of the final
PATIENT DISCHIARGE REFERRAL: EVALUATION OF OBJECTIVES ACHIEVEMEN
copy.
The automated patient discharge referral form has achieved its stated objectives, and the response from both senders and recipients has been positive.
Quality Improvanent and Reearch The capabilities to store and retrieve discharge data are identical to care planning data. Patient and nursing data and information entered in the discharge referral functions are retained online 42 days post-discharge, then transferred to an archival file.
Continuit of Car The patient discharge referral form enhances the continuity of care post-discharge as well as during the hospital stay. Facilities and agencies report that the referral consistently provides more complete data which are essential, clear, concise, and legible. The intricate messaging system afforded by the automated functions facilitates collaborative efforts to plan the patient's discharge.
With appropriate approvals, quality improvement studies and clinical and administrative research can be conducted on the active and archived data.
SUNMMARY The endeavor to produce an interdisciplinary application is a formidable undertaking. With the ultimate, shared goal of interdisciplinary documentation, the phased development and implementation of the patient discharge referral form has created achievable, measurable, and evaluated segments of the envisioned final product. Rather than create a priori the final version, each discipline benefits from the successes and revisions of other disciplines, avoids duplication, and concentrates efforts on specific clinical content. With the successful implementation of the patient discharge referral form by Nursing, other health care
nterdiplinar Car Pla At the present time, the patient discharge referral
form contains patient data and nursing information. Efforts are ongoing to define additional interdisciplinary content and functions to augment and complement the initial patient discharge referral form.
335
disciplines are encouraged to create complementary functions and content.
[4] Hartigan, E. (1987). Discharge planning: Identification of high-risk groups. Nursing Management. 18(12), 30-32.
Referm [1] American Nurses' Association. (1975). Continuity of care and discharge planning programs in institutions and community agencies. (Publication No. NP-49). Kansas City, Missouri: ANA.
[5] Romano, C. (1984). A
computerized approach to discharge care planning. Nursing Outlook. 3(1), 23-25.
[6] Society for Hospital Social Work Directors of the American Hospital Association (1991). Discharge planning update. 11(5), September-October. 1-14.
[2] American Nurses' Association. (1986). Development of computerized nursing information systems in nursing services. (Resolution No. 24). Kansas City, Missouri: ANA.
[7] Prophet, C. (1989). Patient care planning: an interdisciplinary approach. In Proceedings of the thirteenth annual symposium of computer applications in medical care (SCAMC) 823-826. Washington, D.C.:IEEE Computer Society Press.
[3] American Nurses' Association. (1980). Nursing: A social policy statement. Kansas City, Missouri: ANA.
336
