Park Hyeoun-Ae, Min Yul Ha, Jeon Eunjoo, Chung Eunja
Seoul National University College of Nursing, Seoul, Korea.
Healthc Inform Res. 2012 Jun;18(2):136-44. doi: 10.4258/hir.2012.18.2.136. Epub 2012 Jun 30.
The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care.
THIS STUDY WAS CARRIED OUT IN FIVE PHASES: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system.
We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation.
The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system.
本研究旨在测试基于围产期护理详细临床模型和临床实践指南的围产期护理电子护理记录系统的可行性。
本研究分五个阶段进行：1）使用详细临床模型生成护理陈述；2）识别相关证据；3）将护理陈述与证据相联系；4）基于详细临床模型和临床实践指南开发电子护理记录系统原型；5）评估该原型系统。
我们首先使用先前研究中开发的围产期护理详细临床模型的实体、属性和值集，生成了799条描述护理评估、诊断、干预和结果的护理陈述。然后，我们从九条临床实践指南中提取了506条建议，并根据这些建议对护理陈述进行分组，创建了用于护理记录的护理陈述集。最后，我们开发并评估了一个电子护理记录系统原型，该系统可以为护士提供护理实践建议以及基于这些建议的用于指导护理记录的护理陈述集。
该原型系统在内容方面被认为足够完整、相关、有用且适用，在系统用户界面方面易于使用且实用。本研究揭示了开发此类电子护理记录系统的可行性。
