Moss Jacqueline, Coenen Amy, Mills Mary Etta
University of Alabama Birmingham, NB 446, 1530 3rd Ave. South, Birmingham, AL 35294-1210, USA.
J Biomed Inform. 2003 Aug-Oct;36(4-5):271-8. doi: 10.1016/j.jbi.2003.09.006.
The purpose of this study was to evaluate the draft ISO reference terminology model (RTM) for nursing actions. Nursing RTM models attempt to include concepts that are universally represented in nursing documentation to improve the depiction of nursing practice in computerized systems.
Content analysis was used to decompose interventions into words and phrases, which were then mapped to the six model categories used to represent nursing actions in the draft ISO RTM. The decomposition of interventions was applied to nurses' documentation of pain interventions entered into a clinical information system.
Consistent with the ISO standard requirements, all (100.00%) of the interventions contained an
It is recommended that terminology and information system developers consider this model in their ongoing system development, evaluation, maintenance, and revisions. Further evaluation of the ISO RTM for nursing will contribute to the goals of this specific model and the harmonization and integration with other health care models.
本研究旨在评估国际标准化组织（ISO）护理行动参考术语模型（RTM）草案。护理RTM模型试图纳入护理文件中普遍存在的概念，以改进计算机系统中对护理实践的描述。
采用内容分析法将干预措施分解为单词和短语，然后将其映射到ISO RTM草案中用于表示护理行动的六个模型类别。干预措施的分解应用于护士录入临床信息系统的疼痛干预文件。
与ISO标准要求一致，所有（100.00%）干预措施都包含一个<行动>单词或短语和一个<<目标>>。还结合早期术语模型研究讨论了其他结果。
建议术语和信息系统开发者在其正在进行的系统开发、评估、维护和修订中考虑此模型。对ISO护理RTM的进一步评估将有助于实现该特定模型的目标，并与其他医疗保健模型实现协调和整合。
