迈向临床护理信息的数据标准。
Toward data standards for clinical nursing information.
作者信息
Ozbolt J G, Fruchtnicht J N, Hayden J R
机构信息
University of Virginia Health Sciences Center, Charlottesville 22903-3395, USA.
出版信息
J Am Med Inform Assoc. 1994 Mar-Apr;1(2):175-85. doi: 10.1136/jamia.1994.95236147.
OBJECTIVE
Develop standard terms and codes for recording nursing care information in patient records to permit relevant data to be abstracted into a shared database for effectiveness research.
DESIGN
A collaborative effort by the University of Virginia, Thomas Jefferson University Hospital, and the University Hospital Consortium to develop a set of terms to represent specific examples of nursing diagnoses/patient care problems, nursing interventions/patient care activities, and patient outcomes. Terms found in standards of care are being compiled, classified, and coded.
RESULTS
Standard terminology and codes have been developed for 209 nursing diagnoses/patient care problems, 122 expected patient outcomes, and 545 interventions/patient care activities. The terms come from five nursing units in one hospital and from two units in a second hospital. Preliminary findings suggest that in the specialty areas for which terms have been developed, the terms are adequate to capture these types of nursing data in the patient record.
目的
制定用于在患者记录中记录护理信息的标准术语和代码，以便将相关数据提取到共享数据库中进行有效性研究。
设计
弗吉尼亚大学、托马斯·杰斐逊大学医院和大学医院联合会共同努力，制定一套术语，以代表护理诊断/患者护理问题、护理干预/患者护理活动和患者结局的具体示例。正在对护理标准中的术语进行汇编、分类和编码。
结果
已为209项护理诊断/患者护理问题、122项预期患者结局以及545项干预措施/患者护理活动制定了标准术语和代码。这些术语来自一家医院的五个护理单元以及另一家医院的两个单元。初步研究结果表明，在已制定术语的专业领域中，这些术语足以在患者记录中捕获此类护理数据。
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