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电子护理记录:对护理的重要性及在健康信息系统中实施的益处——一项范围综述

Electronic Nursing Records: Importance for Nursing and Benefits of Implementation in Health Information Systems-A Scoping Review.

作者信息

Taneva Daniela Ivova, Gyurova-Kancheva Vasilka Todorova, Kirkova-Bogdanova Angelina Georgieva, Paskaleva Diana Angelova, Zlatanova Yovka Tinkova

机构信息

Department of Nursing Care, Faculty of Public Health, Medical University-Plovdiv, 4004 Plovdiv, Bulgaria.

Department of Medical Informatics, Biostatistics and Elearning, Faculty of Public Health, Medical University-Plovdiv, 4002 Plovdiv, Bulgaria.

出版信息

Nurs Rep. 2024 Nov 18;14(4):3585-3605. doi: 10.3390/nursrep14040262.

Abstract

: The advancement of nursing science and practice necessitates the documentation of information, which is increasingly being recorded in electronic mediums due to the progress of information technology. Various countries around the world have implemented electronic nursing records (ENRs) or are in the process of implementing them. This study aims to ascertain the significance of electronic nursing records and consolidate their primary benefits for nursing. : The study utilized an established scoping review methodology (Arksey and O'Malley protocol; JBI method; PRISMA ScR (2018)). : Out of 6970 initial articles extracted from four databases, 36 were included in the study. Several essential elements for structuring, introducing, and emphasizing the importance of ENRs have been recognized, including the availability of standardized terminology, enhancement of nursing care quality, advancement of research activity, integration with electronic systems, optimization of healthcare, and conditions for ENR integration. : Electronic nursing records are indispensable and beneficial for enhancing care quality, improving patient safety, and affirming the autonomy of the nursing profession.

摘要

护理科学与实践的发展需要对信息进行记录,由于信息技术的进步,这些信息越来越多地以电子媒介记录。世界各国已实施或正在实施电子护理记录(ENR)。本研究旨在确定电子护理记录的重要性,并总结其对护理的主要益处。

本研究采用既定的范围综述方法(阿克斯和奥马利方案;JBI方法;PRISMA ScR(2018))。

从四个数据库中提取的6970篇初始文章中,有36篇被纳入研究。已确定了构建、引入和强调电子护理记录重要性的几个关键要素,包括标准化术语的可用性、护理质量的提高、研究活动的推进、与电子系统的集成、医疗保健的优化以及电子护理记录集成的条件。

电子护理记录对于提高护理质量、改善患者安全以及维护护理专业的自主性不可或缺且有益。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/b63f/11587436/6eae0a048954/nursrep-14-00262-g001.jpg

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