Monsen Karen A, Fitzsimmons Laura L, Lescenski Barbara A, Lytton Amy B, Schwichtenberg Linda D, Martin Karen S
Washington County Department of Public Health and Environment, Stillwater, MN 55082, USA.
Comput Inform Nurs. 2006 May-Jun;24(3):152-8. doi: 10.1097/00024665-200605000-00012.
Automation of nursing documentation in client records is one of today's formidable challenges in healthcare settings. Some stakeholders view standardized nursing language as a fundamental component of an automated record, with the end goal of generating valid, reliable data on nursing services and client outcomes. However, few successful applications of standardized nursing language for practice standards and data generation exist in the literature. A joint practice-and-data quality project based on standardized nursing language in an automated platform was undertaken by four local public health departments. Outcomes of this project included articulation of standards for nursing practice and creation and implementation of a sound data quality infrastructure for nursing documentation of client assessments, service delivery information, and client outcomes.
在医疗环境中,实现客户记录中护理文档的自动化是当今一项艰巨的挑战。一些利益相关者将标准化护理语言视为自动化记录的基本组成部分,最终目标是生成关于护理服务和客户结果的有效、可靠数据。然而,文献中很少有将标准化护理语言成功应用于实践标准和数据生成的案例。四个当地公共卫生部门开展了一个基于自动化平台上标准化护理语言的联合实践与数据质量项目。该项目的成果包括明确护理实践标准,以及创建和实施一个完善的数据质量基础设施,用于记录客户评估、服务提供信息和客户结果的护理文档。