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使用电子病历系统促进标准化护理语言。

Promoting standardized nursing language using an electronic medical record system.

作者信息

Doyle Marc

机构信息

Jackson Health System, Miami, USA.

出版信息

AORN J. 2006 Jun;83(6):1336-42; quiz 1345-8. doi: 10.1016/s0001-2092(06)60147-6.

Abstract

Paper-based medical record systems are becoming obsolete with the advent of electronic medical record (EMR) systems. With EMRs, patient data can be accessed instantly, patients can be tracked intelligently, and safeguards can help prevent medical errors. By integrating a universal nursing language, such as the Perioperative Nursing Data Set (PNDS), into EMR systems, nurses can document the nursing care they give to patients. This allows nurses to show the value of their role in the OR, promote nursing, and explain how their actions help meet National Patient Safety Goals. The transition to an EMR system for Jackson Health System, Miami, is discussed, including integration of the PNDS into the EMR system.

摘要

随着电子病历(EMR)系统的出现,纸质病历系统正逐渐过时。借助电子病历,患者数据可即时获取,患者能够得到智能跟踪,并且安全措施有助于防止医疗差错。通过将通用护理语言(如围手术期护理数据集(PNDS))集成到电子病历系统中,护士可以记录他们为患者提供的护理。这使护士能够展示其在手术室中的角色价值、促进护理工作,并解释其行动如何有助于实现国家患者安全目标。本文讨论了迈阿密杰克逊健康系统向电子病历系统的过渡,包括将围手术期护理数据集集成到电子病历系统中。

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