通过护理干预分类法实现成功的跨学科记录。
Successful interdisciplinary documentation through nursing interventions classification.
作者信息
Smith Kathleen, Smith Vivienne
机构信息
University of Colorado Hospital, Box AO21-360, 4200 E Ninth Ave, Denver, CO 80262, USA.
出版信息
Semin Nurse Manag. 2002 Jun;10(2):100-4.
Automated documentation systems enable health care professionals to develop dynamic, interdisciplinary care plans. Use of a standardized nomenclature provides a common framework and language for the communication of the plan, and also can support data collection to determine best clinical practices. A comprehensive patient care record will link the interdisciplinary care plan to clinical charting and the documentation of outcomes. This article reviews efforts to improve interdisciplinary communication by computerizing the documentation system, using the Nursing Interventions Classification (NIC).
自动化文档系统使医疗保健专业人员能够制定动态的跨学科护理计划。使用标准化术语为护理计划的沟通提供了一个通用框架和语言，还能支持数据收集以确定最佳临床实践。全面的患者护理记录将跨学科护理计划与临床图表及结果记录相联系。本文回顾了通过使用护理干预分类法（NIC）将文档系统计算机化来改善跨学科沟通的相关努力。
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