Orlygsdóttir Brynja
University of Iowa, College of Nursing, USA.
Comput Inform Nurs. 2007 Sep-Oct;25(5):283-93. doi: 10.1097/01.NCN.0000289165.61863.d0.
If the Nursing Minimum Data Set elements, specifically the nursing care elements, are included in a clinical information system, nursing will be able to measure outcomes and contributions to both healthcare and nursing to build knowledge using clinical data. The purpose of the reported study was to determine whether a Nursing Information and Data Set Evaluation Center-compliant clinical information system using the Omaha System could support the Nursing Minimum Data Set goal to describe nursing care in a community health setting. The secondary data set analysis was conducted. The findings showed that although the clinical information system was compliant with the standard, used a recognized American Nurses Association nursing vocabulary, and supported the collection of the Nursing Minimum Data Set, the data were not sufficient to address the purposes of the Nursing Minimum Data Set. The implications for nursing research and clinical practice are outlined.
如果护理最低数据集元素，特别是护理照顾元素，被纳入临床信息系统，护理人员将能够衡量结果以及对医疗保健和护理的贡献，以便利用临床数据积累知识。本报告研究的目的是确定一个符合护理信息与数据集评估中心标准、采用奥马哈系统的临床信息系统，是否能够支持护理最低数据集在社区卫生环境中描述护理照顾的目标。进行了二次数据集分析。结果表明，尽管该临床信息系统符合标准，使用了美国护士协会认可的护理词汇，并支持护理最低数据集的收集，但数据并不足以实现护理最低数据集的目标。文中概述了对护理研究和临床实践的启示。
