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日本关于标准化护理实践术语主文件使用情况的医院调查。

A hospital survey on the utilization of the master file of the standardized nursing practice terminology in Japan.

作者信息

Tsuru Satoko, Wako Fumiko, Watanabe Chitose, Uchiyama Makiko, Okamine Eiko, Inoue Manami, Omori Miho

机构信息

School of Engineering, The University of Tokyo, Japan.

出版信息

Stud Health Technol Inform. 2013;192:1174.

Abstract

A common language in nursing facilitates better communication among nurses and other healthcare providers, assuring better nursing care, hence better patient outcomes. As we developed and disseminated the standardized terminology of nursing which provided nurses with a set of terms to describe nursing observations and nursing actions, we run a survey to see how much it was recognized and utilized in actual clinical settings. The result showed that approximately 60% of the respondents were cognizant of our terminology, and again 60% of them were either actually using the terminology or interested in using it in the future. For them, the main purposes of utilizing the terminology were nursing documentation and care planning. Sometimes it was used as an educational tool. This suggests that we should further develop a tool to assist nurses with their documentation and care planning alongside the revision of the terminology itself.

摘要

护理领域的通用语言有助于护士与其他医疗服务提供者之间进行更好的沟通,确保提供更好的护理服务,从而改善患者的治疗效果。在我们开发并推广护理标准化术语(该术语为护士提供了一套用于描述护理观察和护理行动的术语)的过程中,我们开展了一项调查,以了解其在实际临床环境中的被认可程度和使用情况。结果显示,约60%的受访者知晓我们的术语,其中又有60%的人实际正在使用该术语或有意在未来使用。对他们而言,使用该术语的主要目的是护理记录和护理计划。有时它也被用作一种教育工具。这表明我们在修订术语本身的同时,应进一步开发一种工具来协助护士进行记录和护理计划。

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