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芬兰癌症中心与电子健康记录中的国家文档模型——用户反馈与发展建议

FinCC and the National Documentation Model in EHR--user feedback and development suggestions.

作者信息

Kinnunen Ulla-Mari, Junttila Kristiina, Liljamo Pia, Sonninen Anna Liisa, Härkönen Mikko, Ensio Anneli

机构信息

University of Eastern Finland, Kuopio, Finland.

Hospital District of Helsinki and Uusimaa, Helsinki, Finland.

出版信息

Stud Health Technol Inform. 2014;201:196-202.

Abstract

The structure of the Finnish nursing documentation model is based on the decision-making process and a standardized nursing terminology: Finnish Care Classification (FinCC). Nearly 20,000 nurses use the FinCC although not all healthcare organizations utilize it. Development projects for the common national nursing documentation framework have been carried out, for example, in 2010-2011 the aim of a project by the Ministry of Social Affairs and Health and the National Institute of Health and Welfare was to suggest recommendations for the Finnish nursing documentation model. The final report of the project was sent to different organizations all over the country for further feedback statements. The aim of this paper is to summarize the message of the statements (n=37) from primary and specialized care, universities including universities of applied science, professional nursing associations, trade unions and national authorities. Development suggestions for the FinCC and electronic health records will be introduced.

摘要

芬兰护理文件记录模式的结构基于决策过程和一种标准化的护理术语

芬兰护理分类法(FinCC)。近20000名护士使用FinCC,尽管并非所有医疗保健机构都采用它。已经开展了国家通用护理文件记录框架的开发项目,例如,2010 - 2011年社会事务与卫生部以及国家健康与福利研究所开展的一个项目,旨在为芬兰护理文件记录模式提出建议。该项目的最终报告已发送至全国不同组织以获取进一步的反馈意见。本文旨在总结来自初级和专科护理机构、包括应用科学大学在内的大学、专业护理协会、工会以及国家当局的37份反馈意见的要点。还将介绍针对FinCC和电子健康记录的发展建议。

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