Westra Bonnie L, Delaney Connie White, Konicek Debra, Keenan Gail
University of Minnesota School of Nursing, Minneapolis, MN 55455, USA.
Nurs Outlook. 2008 Sep-Oct;56(5):258-266.e1. doi: 10.1016/j.outlook.2008.06.005.
Quality and low cost health care that is free of medical mistakes requires continuity of person-centric healthcare information across the life span and healthcare settings. Interoperable clinical information systems that rely on the use of multiple standards to support health information exchange and, in particular, nurse sensitive data, information, and knowledge are key components to support high quality, safe care. A 2004 Executive Order called for a National Health Information Network and the widespread adoption of electronic health records (EHRs) by 2014. While there are numerous standards influencing the exchange of health data, the primary focus of this article is to synthesize the state-of-the-art in nursing standardized terminologies to support the development, exchange, and communication of nursing data. Research exemplars are described for information systems to support nursing practice using standardized terminologies and secondary use of standardized nursing data from EHRs for knowledge development.
高质量且低成本、无医疗差错的医疗保健需要在整个生命周期和医疗环境中保持以患者为中心的医疗保健信息的连续性。可互操作的临床信息系统依赖于使用多种标准来支持健康信息交换，尤其是护士敏感数据、信息和知识，是支持高质量、安全护理的关键组成部分。2004年的一项行政命令呼吁建立国家卫生信息网络，并在2014年前广泛采用电子健康记录（EHR）。虽然有许多标准影响健康数据的交换，但本文的主要重点是综合护理标准化术语的最新情况，以支持护理数据的开发、交换和交流。描述了研究范例，用于支持使用标准化术语进行护理实践的信息系统，以及将EHR中的标准化护理数据用于知识开发的二次使用。
