Brazile R P, Hettinger B J
University of North Texas, Denton, USA.
Comput Nurs. 1995 Jul-Aug;13(4):151-8.
This article describes a clinical information system developed for ambulatory care nurse practitioners. An overview of the clinical information system is presented, followed by a detailed description. The clinical information system uses the relational database structure proposed by Hettinger and Brazile (1992), and creates a longitudinal electronic health care record. The database design includes the Nursing Minimum Data Set and provides links to external aggregate data sets such as the U. S. Census data. Special features are discussed such as the ability to select from several problem classification schemes, including North American Nursing Diagnosis Association, Omaha, and International Classification of Diseases, 9th Revision; insert new menu selections whenever needed; create and track groups; and store detailed outcome data. A brief summary of implementation considerations is included.
本文介绍了一个为门诊护理从业者开发的临床信息系统。先对该临床信息系统进行了概述,随后进行了详细描述。该临床信息系统采用了赫廷格和布拉齐尔(1992年)提出的关系数据库结构,并创建了一份纵向电子医疗记录。数据库设计包括护理最小数据集,并提供与外部汇总数据集(如美国人口普查数据)的链接。文中讨论了该系统的一些特殊功能,例如能够从多种问题分类方案中进行选择,包括北美护理诊断协会、奥马哈和《国际疾病分类》第九版;可根据需要插入新的菜单选项;创建和跟踪群组;以及存储详细的结果数据。文中还包括了对实施注意事项的简要总结。