Department of Health and Social Management, University of Eastern Finland (Kuopio Campus), Savilahdentie 6 A 3krs., P.O. Box 1627, FIN-70211 Kuopio, Finland.
Int J Med Inform. 2010 Aug;79(8):554-64. doi: 10.1016/j.ijmedinf.2010.05.002.
The purpose of this study was to describe and evaluate whether nurses have documented patient care in compliance with the national nursing documentation model in electronic health records, which means the use of the nursing process and the use of standardized terminology in different phases of the nursing process.
The data were collected from a central hospital in 2003-2006. The data consist of the electronic nursing care plans of 67 neurological patients and 422 surgical patients. The data were analyzed using statistical methods and content analysis.
Standardized electronic nursing documentation is based on the nursing process, although the use of the nursing process varies across patients. There is a lack of progress notes relating to needs assessment, the identification of nursing diagnoses and care aims, and the nursing interventions planned in the documentation. The standardized terminology is used in the documentation but inconsistencies emerge in the use of the different classifications.
The national model for electronic nursing documentation is suitable for the documentation of patient care in nursing care plans. However, health care professionals need further training in documenting patient care according to the nursing process, and in using the terminology in order to increase patient safety and improve documentation.
本研究旨在描述并评估护士是否按照国家护理记录模型在电子健康记录中记录患者护理，这意味着在护理过程的不同阶段使用护理过程和使用标准化术语。
数据收集自 2003 年至 2006 年的一家中心医院。数据包括 67 例神经科患者和 422 例外科患者的电子护理护理计划。使用统计方法和内容分析对数据进行了分析。
标准化电子护理记录基于护理过程，尽管患者之间护理过程的使用有所不同。在文档中缺乏与需求评估、护理诊断和护理目标的确定以及计划的护理干预相关的进展记录。在文档中使用了标准化术语，但在不同分类的使用中出现了不一致。
国家电子护理记录模型适合在护理计划中记录患者护理。然而，医疗保健专业人员需要进一步培训，以按照护理过程记录患者护理，并使用术语，以提高患者安全性并改善文档记录。
