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本文引用的文献

1
Testing of an audit instrument for the nursing discharge note in the patient record.对患者病历中护理出院记录审核工具的测试。
Scand J Caring Sci. 2004 Sep;18(3):318-24. doi: 10.1111/j.1471-6712.2004.00288.x.
2
Challenging the information gap--the patients transfer from hospital to home health care.挑战信息鸿沟——患者从医院向家庭医疗护理的过渡
Int J Med Inform. 2004 Aug;73(7-8):569-80. doi: 10.1016/j.ijmedinf.2004.04.009.
3
Structuring the documentation of nursing care on the basis of a theoretical process model.基于理论流程模型构建护理记录。
Scand J Caring Sci. 2004 Jun;18(2):229-36. doi: 10.1111/j.1471-6712.2004.00274.x.
4
[Do general practitioners know what medication community nurses give their shared patients?].全科医生知道社区护士给他们共同护理的患者用了什么药物吗?
Tidsskr Nor Laegeforen. 2004 Mar 18;124(6):810-2.
5
Improving safety with information technology.利用信息技术提高安全性。
N Engl J Med. 2003 Jun 19;348(25):2526-34. doi: 10.1056/NEJMsa020847.
6
Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study.影响和受基于计算机的护理记录用户接受度影响的因素:一项为期两年的研究结果
J Am Med Inform Assoc. 2003 Jan-Feb;10(1):69-84. doi: 10.1197/jamia.m1118.
7
Developing a module for nursing documentation integrated in the electronic patient record.开发一个集成在电子病历中的护理文档模块。
J Clin Nurs. 2001 Nov;10(6):799-805. doi: 10.1046/j.1365-2702.2001.00557.x.
8
Continuity of hospital care: beyond the question of personal contact.医院护理的连续性:超越个人接触的问题。
BMJ. 2002 Jan 5;324(7328):36-8. doi: 10.1136/bmj.324.7328.36.
9
Doctors' use of electronic medical records systems in hospitals: cross sectional survey.医院中医生对电子病历系统的使用:横断面调查
BMJ. 2001 Dec 8;323(7325):1344-8. doi: 10.1136/bmj.323.7325.1344.
10
Nursing process documentation systems in clinical routine--prerequisites and experiences.临床常规护理流程记录系统——前提条件与经验
Int J Med Inform. 2001 Dec;64(2-3):187-200. doi: 10.1016/s1386-5056(01)00216-7.

护士在患者从医院出院至家庭护理阶段的信息管理。

Nurses' information management at patients' discharge from hospital to home care.

作者信息

Hellesø Ragnhild, Sorensen Lena, Lorensen Margarethe

机构信息

Faculty of Medicine, Institute of Nursing and Health Sciences, University of Oslo, P.O. Box 1153 Blindern, NO-0318 Oslo, Norway.

出版信息

Int J Integr Care. 2005;5:e12. doi: 10.5334/ijic.133. Epub 2005 Jul 8.

DOI:10.5334/ijic.133
PMID:16773162
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC1395517/
Abstract

PURPOSE

The purpose of this paper is to explore and compare hospital and home care nurses' assessment of their information management at patients' discharge from hospital to home care before and after the hospital implemented an electronic nursing discharge note.

THEORY

This paper draws on the concept of inter-organizational continuity of care, and specifically addresses the contribution of the implementation of an electronic patient record (EPR).

METHODS

The study has a prospective descriptive design. A questionnaire addressing the information that hospital and home care nurses exchange when patients need continuing care after hospitalization was developed and used.

RESULTS

Hospital and home care nurses differed in the way they assessed the structures and content of the information they exchanged, both before and after the EPR implementation.

CONCLUSION AND DISCUSSION

There is a need to take account of the different organizational contexts within which the two nursing groups work. The organizational context (hospital versus home care) has implications for the nurses' assessment of the information they exchange. In further development of EPR, it is therefore essential to clarify the context-related information needs of the various health care provider groups as part of the commitment to patient safety.

摘要

目的

本文旨在探讨并比较在医院实施电子护理出院记录前后,医院护士和家庭护理护士对患者从医院出院至家庭护理阶段信息管理的评估。

理论

本文借鉴了组织间连续性护理的概念,并特别探讨了电子病历(EPR)实施的作用。

方法

本研究采用前瞻性描述性设计。编制并使用了一份问卷,该问卷涉及医院和家庭护理护士在患者住院后需要持续护理时所交换的信息。

结果

在实施电子病历前后,医院护士和家庭护理护士对他们所交换信息的结构和内容的评估方式均存在差异。

结论与讨论

有必要考虑两个护理群体工作所处的不同组织背景。组织背景(医院与家庭护理)对护士对他们所交换信息的评估有影响。因此,在电子病历的进一步发展中,作为对患者安全承诺的一部分,明确各医疗服务提供群体与背景相关的信息需求至关重要。