Anderson Christine A, Keenan Gail, Jones Josette
University of Michigan School of Nursing, Ann Arbor, MI 48109, USA.
Comput Inform Nurs. 2009 Mar-Apr;27(2):82-90; quiz 91-2. doi: 10.1097/NCN.0b013e3181972a24.
Nurses are being pressured to integrate standardized nursing terminology into the electronic health record to enable the representation and evaluation of nursing practice. Five terminology sets are recognized by the American Nurses Association that contain terms to represent nursing diagnoses, outcomes, and intervention: CCC, ICNP, NANDA/NOC/NIC, Omaha System, and PNDS. Key criteria for choosing the most suitable include demonstrated use and testing under real-time clinical conditions, scope of terms, cost, and the administrative infrastructure to sustain and evolve the terminology. Likelihood of survival is also critical and was evaluated here by examining the diffusion pattern of each terminology set through bibliometric analysis. Each of the five sets had a unique diffusion pattern, with NANDA/NOC/NIC demonstrating the most extensive penetration and author network in the CINAHL literature examined from 1982 to 2006.
护士们面临着将标准化护理术语整合到电子健康记录中的压力,以便对护理实践进行呈现和评估。美国护士协会认可了五套术语集,其中包含用于表示护理诊断、结果和干预措施的术语:CCC、ICNP、NANDA/NOC/NIC、奥马哈系统和PNDS。选择最合适术语集的关键标准包括在实时临床条件下的实际使用和测试、术语范围、成本以及维持和发展该术语的管理基础设施。生存可能性也至关重要,本文通过文献计量分析研究各术语集的传播模式来对此进行评估。这五套术语集中的每一套都有独特的传播模式,在1982年至2006年检查的CINAHL文献中,NANDA/NOC/NIC显示出最广泛的渗透和作者网络。