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临床数据库的演变:从本地语言到标准化临床语言。

The evolution of a clinical database: from local to standardized clinical languages.

作者信息

Prophet C M

机构信息

Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242-1009, USA.

出版信息

Proc AMIA Symp. 2000:660-4.

Abstract

For more than twenty years, the University of Iowa Hospitals and Clinics Nursing Informatics (UIHC NI) has been developing a clinical database to support patient care planning and documentation in the INFORMM NIS (Information Network for Online Retrieval & Medical Management Nursing Information System). Beginning in 1992, the database content was revised to standardize orders and to incorporate the Standardized Nursing Languages (SNLs) of the North American Nursing Diagnosis Association (NANDA), Nursing Diagnosis Extension Classification (NDEC), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC). This paper reports the results of the database revision as well as recent usage data, new user selection methods for clinical content, and the advantages of a database utilizing SNLs.

摘要

二十多年来,爱荷华大学医院及诊所护理信息学(UIHC NI)一直在开发一个临床数据库,以支持INFORMM NIS(在线检索与医疗管理护理信息系统信息网络)中的患者护理计划和文档记录。从1992年开始,数据库内容进行了修订,以规范医嘱并纳入北美护理诊断协会(NANDA)、护理诊断扩展分类(NDEC)、护理干预分类(NIC)和护理结果分类(NOC)的标准化护理语言(SNLs)。本文报告了数据库修订的结果以及近期的使用数据、临床内容的新用户选择方法,以及使用SNLs的数据库的优势。

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