Oulu University Hospital, Finland; University of Eastern Finland, Finland.
University of Eastern Finland, Finland.
Health Informatics J. 2020 Mar;26(1):114-128. doi: 10.1177/1460458218813613. Epub 2018 Dec 5.
Patient-care data from the electronic health record systems are increasingly in demand for re-use in administration and resource planning. Nursing documentation with coded concepts is expected to produce more reliable data, fulfilling better requirements for re-use. The aim was to ascertain what kind of relation exist between coded nursing diagnoses, nursing interventions, and nursing intensity and to discuss the possibilities for re-using nursing data for workload design. We analysed the retrospective nursing records of 794 patients documented by the Finnish Care Classification and nursing intensity data assessed by the Oulu Patient Classification over a 15-day period in nine inpatient units at a university hospital. Using the generalised linear mixed model, the clear relationship between the number of coded nursing notes and nursing intensity levels were ascertained. The number of coded nursing notes increases when the nursing intensity increases. The outcomes construct a good basis for continuing elaboration of electronic health record data re-use.
患者护理数据越来越多地从电子健康记录系统中被要求重新用于管理和资源规划。编码概念的护理文档有望生成更可靠的数据，更好地满足重新使用的要求。目的是确定编码护理诊断、护理干预和护理强度之间存在什么样的关系，并讨论重新使用护理数据进行工作量设计的可能性。我们分析了在大学医院的九个住院病房中，在 15 天内使用芬兰护理分类法记录的 794 名患者的回顾性护理记录和使用奥卢患者分类法评估的护理强度数据。使用广义线性混合模型，确定了编码护理记录数量与护理强度水平之间的明确关系。当护理强度增加时，编码护理记录的数量也会增加。这些结果为进一步完善电子健康记录数据的再利用奠定了良好的基础。
