Bowles K H
University of Pennsylvania School of Nursing, Philadelphia 19104-6096, USA.
Res Nurs Health. 2000 Apr;23(2):93-105. doi: 10.1002/(sici)1098-240x(200004)23:2<93::aid-nur2>3.0.co;2-k.
Although effective as a standardized language for documentation in community and public health settings, the Omaha System has not been evaluated in acute care settings. The purpose of this study was to evaluate the utility of the Omaha System to code the terms used by nurses when documenting hospital care. The nursing documentation in 30 hospital records was content analyzed for signs and symptoms, patient problems, and nursing interventions, then coded into the categories of the Omaha System. Degree of match was evaluated using concept match scores, and utility was determined using empirical, operational, and pragmatic criteria. Study findings suggest several strengths (i.e., high reliability, coded 97% of the problems, easy to use) and some limitations (lack of mutual exclusivity among terms, lack of semantic clarity, the need for three new problems). This study has important implications in demonstrating the utility of the Omaha System for possible expansion into acute care to standardize communication between the hospital setting and home care.
尽管奥马哈系统作为社区和公共卫生环境中记录的标准化语言很有效，但尚未在急性护理环境中进行评估。本研究的目的是评估奥马哈系统对护士记录医院护理时使用的术语进行编码的效用。对30份医院记录中的护理记录进行内容分析，以确定体征和症状、患者问题及护理干预措施，然后将其编码为奥马哈系统的类别。使用概念匹配分数评估匹配程度，并使用实证、操作和实用标准确定效用。研究结果表明了该系统的几个优点（即高可靠性、对97%的问题进行了编码、易于使用）和一些局限性（术语之间缺乏互斥性、语义清晰度不足、需要三个新问题）。本研究对于证明奥马哈系统扩展到急性护理以规范医院环境与家庭护理之间沟通的效用具有重要意义。
