PhD student, Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal.
Invited Researcher, CIDESI-ESEP: ICN-Accredited Centre for Information Systems and ICNP Research and Development of Nursing School of Porto, Porto, Portugal.
Int Nurs Rev. 2023 Sep;70(3):383-393. doi: 10.1111/inr.12820. Epub 2023 Jan 14.
This study aims to (1) analyse all self-care-related interventions Portuguese nurses documented, (2) determine potential issues that may impair semantic interoperability and (3) propose a new set of interventions representing nursing actions regarding self-care that may integrate any HER application.
As populations age and chronic diseases increase, self-care concerns rise. Individuals who seek healthcare, regardless of context, need prompt access to accurate health information. Healthcare professionals need to understand the information in all places where care is provided, creating the need for semantic interoperability within electronic health records.
A qualitative descriptive and exploratory study was conducted in two phases: (1) a content analysis of nursing interventions e-documentation and (2) a focus group with fifteen registered nurses exploring latent criteria or insights gleaned from the findings of content analysis. The COREQ statement was used to guide research reporting.
We extracted 1529 nursing intervention sentences from the electronic health records and created 209 intervention categories. We identified the main issues with semantic interoperability in nursing intervention identification.
According to the findings, nurses cooperate with clients, offering physical aid and encouraging them to overcome functional limitations to self-care tasks hampered by their conditions.
This article provides evidence to warn policy makers against decisions to use locally customised electronic health records, as well as evidence on the importance of policy promoting the adoption of a nursing ontology for electronic health records. And, as a result, the harmonisation and effective provision of high-quality nursing care and the reduction of healthcare costs across nations.
本研究旨在：(1) 分析葡萄牙护士记录的所有与自我护理相关的干预措施；(2) 确定可能影响语义互操作性的潜在问题；(3) 提出一组新的干预措施，代表与自我护理相关的护理行动，这些干预措施可能集成任何 HER 应用程序。
随着人口老龄化和慢性病的增加，自我护理的问题日益突出。无论在何种情况下寻求医疗保健的人都需要及时获得准确的健康信息。医疗保健专业人员需要在提供护理的所有地方理解信息，这就需要电子健康记录中的语义互操作性。
本研究采用定性描述和探索性研究方法，分为两个阶段进行：(1) 对护理干预电子文档进行内容分析；(2) 对 15 名注册护士进行焦点小组讨论，以探索内容分析结果中得出的潜在标准或见解。研究报告采用 COREQ 声明进行指导。
我们从电子健康记录中提取了 1529 个护理干预句子，并创建了 209 个干预类别。我们确定了在护理干预识别中的语义互操作性的主要问题。
根据研究结果，护士与患者合作，提供身体援助并鼓励他们克服功能限制，以完成自我护理任务，这些任务因他们的病情而受阻。
本文提供了证据，警告政策制定者不要做出使用本地定制的电子健康记录的决定，同时也证明了政策促进电子健康记录中采用护理本体的重要性。结果是，在各国之间实现护理的协调和有效提供以及高质量的护理，并降低医疗保健成本。
