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一个将NANDA、NIC和NOC术语整合到电子病历中的框架。

A framework for integrating NANDA, NIC, and NOC terminology in electronic patient records.

作者信息

von Krogh Gunn, Dale Cecilie, Nåden Dagfinn

机构信息

Oslo University College, Faculty of Nursing, Oslo, Norway.

出版信息

J Nurs Scholarsh. 2005;37(3):275-81. doi: 10.1111/j.1547-5069.2005.00047.x.

Abstract

PURPOSE

To describe the methods used in design of a framework that (a) encompasses nursing knowledge, (b) functions as a cognitive map for clinicians, and (c) increases the efficiency of using the North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), and Nursing Outcome Classification (NOC) terminologies together in the electronic patient record.

METHODS

The taxonomies of the NANDA, NIC, and NOC terminologies were integrated to form a preliminary structure of domains and classes. New concepts and collocations of concepts were constructed using Walker and Avant's (1983, 1988) method for concept synthesis. The framework was validated using an expert group and clinical testing.

RESULTS

A framework organized as a taxonomy with eight domains (Physiological, Functional, Psychocognitive, Safety, Existential, Lifestyle, Family, and Environment) and 29 classes.

CONCLUSIONS

The framework has the potential to enhance the quality of nursing documentation, contribute to nursing research and education, and reduce job stress.

摘要

目的

描述用于设计一个框架的方法,该框架要满足以下几点:(a)涵盖护理知识;(b)作为临床医生的认知地图发挥作用;(c)提高在电子病历中同时使用北美护理诊断协会(NANDA)、护理干预分类(NIC)和护理结果分类(NOC)术语的效率。

方法

整合NANDA、NIC和NOC术语的分类法,形成领域和类别的初步结构。使用沃克和阿万特(1983年、1988年)的概念合成方法构建新概念和概念搭配。通过专家组和临床测试对该框架进行验证。

结果

一个组织为分类法的框架,有八个领域(生理、功能、心理认知、安全、存在、生活方式、家庭和环境)和29个类别。

结论

该框架有可能提高护理文件的质量,促进护理研究和教育,并减轻工作压力。

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