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绘制奥马哈系统数据的即时护理审核筛查表

Mapping Out Point-of-Care Review Screens for Omaha System Data.

作者信息

Lee Seonah

机构信息

Author Affiliation: College of Nursing, University of Missouri.

出版信息

Comput Inform Nurs. 2016 Feb;34(2):85-91. doi: 10.1097/CIN.0000000000000215.

Abstract

Omaha System data are text data that consist of standardized terminology and customized descriptions. The customized descriptions related to patient care reveal changes in a client's status over time. These data help public health nurses to understand the patient's progress and to plan future care. However, most electronic health records do not provide clinicians with efficient displays of stored text data. The purpose of this study is to develop point-of-care review screens for Omaha System data on an individual patient level and examine nurse perceptions of the usefulness of the displayed data in improving patient care. Individual patients' data were organized on a Web-based overview page to present all of the health problems that a client had and on detailed pages to present all records of Omaha System data regarding each health problem. Nurse survey results indicated the usefulness of at-a-glance displays of text data on patient care and nurses' decision making. The meaningful review of patient data using a health information system supports patient-data-driven, evidence-based practice and decision making.

摘要

奥马哈系统数据是由标准化术语和定制化描述组成的文本数据。与患者护理相关的定制化描述揭示了患者状况随时间的变化。这些数据有助于公共卫生护士了解患者的进展并规划未来护理。然而,大多数电子健康记录并未向临床医生有效展示存储的文本数据。本研究的目的是在个体患者层面开发奥马哈系统数据的即时护理审查屏幕,并考察护士对所展示数据在改善患者护理方面有用性的看法。个体患者的数据在基于网络的概述页面上进行整理,以呈现患者所有的健康问题,并在详细页面上呈现关于每个健康问题的奥马哈系统数据的所有记录。护士调查结果表明,文本数据的一目了然展示对患者护理和护士决策有用。使用健康信息系统对患者数据进行有意义的审查,支持以患者数据为驱动、基于证据的实践和决策。

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