Bernhart-Just Alexandra, Hillewerth Kathrin, Holzer-Pruss Christina, Paprotny Monika, Zimmermann Heinrich Heidi
Zentrum für Entwicklung und Forschung Pflege, UniversitätsSpital Zürich.
Pflege. 2009 Dec;22(6):443-54. doi: 10.1024/1012-5302.22.6.443.
The data model developed on behalf of the Nursing Service Commission of the Canton of Zurich (Pflegedienstkommission des Kantons Zürich) is based on the NANDA nursing diagnoses, the Nursing Outcome Classification, and the Nursing Intervention Classification (NNN Classifications). It also includes integrated functions for cost-centered accounting, service recording, and the Swiss Nursing Minimum Data Set. The data model uses the NNN classifications to map a possible form of the nursing process in the electronic patient health record, where the nurse can choose nursing diagnoses, outcomes, and interventions relevant to the patient situation. The nurses' choice is guided both by the different classifications and their linkages, and the use of specific text components pre-defined for each classification and accessible through the respective linkages. This article describes the developed data model and illustrates its clinical application in a specific patient's situation. Preparatory work required for the implementation of NNN classifications in practical nursing such as content filtering and the creation of linkages between the NNN classifications are described. Against the background of documentation of the nursing process based on the DAPEP(1) data model, possible changes and requirements are deduced. The article provides a contribution to the discussion of a change in documentation of the nursing process by implementing nursing classifications in electronic patient records.
代表苏黎世州护理服务委员会(Pflegedienstkommission des Kantons Zürich)开发的数据模型基于北美护理诊断协会(NANDA)护理诊断、护理结局分类和护理干预分类(NNN分类)。它还包括以成本为中心的会计核算、服务记录以及瑞士护理最小数据集的集成功能。该数据模型使用NNN分类在电子患者健康记录中描绘护理过程的一种可能形式,护士可以在其中选择与患者情况相关的护理诊断、结局和干预措施。护士的选择既受不同分类及其关联的指导,也受为每个分类预先定义并可通过各自关联访问的特定文本组件的使用的指导。本文描述了所开发的数据模型,并说明了其在特定患者情况中的临床应用。描述了在实际护理中实施NNN分类所需的准备工作,如内容筛选以及NNN分类之间的关联创建。基于DAPEP(1)数据模型的护理过程记录背景下,推导了可能的变化和要求。本文通过在电子患者记录中实施护理分类,为护理过程记录的变化讨论做出了贡献。