Anderson B, Hannah K J
Can J Nurs Adm. 1993 May-Jun;6(2):7-13.
Through a selected review of existing hospital and health care minimum data sets in the United States, the United Kingdom and Canada, the authors expose the nursing data gaps in those data sets. Nurses in the United States have responded to these data gaps through the development of a Nursing Minimum Data Set (NMDS). The NMDS is a tool for abstracting a uniform collection of essential nursing data from the patient record usually at hospital discharge. The nursing care data elements in the NMDS include: nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care. A major factor influencing the move to generate an NMDS in Canada is the response to the need to contain rising health care costs while maintaining quality health care. The NMDS has profound implications for nurses in all practice settings through use of these data in: costing of nursing services; defending resource allocation to nursing; defining nursing's contribution to patient care; defining outcomes of nursing care; developing nursing knowledge; and continued growth of nursing as a profession. Initiatives in Canada directed at the development of an NMDS indicate a heightened awareness of the need for the collection, storage and retrieval of nursing data. However, nurses in Canada have yet to define the essential nursing data elements for inclusion in a national health information system for use in Canada.
通过对美国、英国和加拿大现有的医院及医疗保健最小数据集进行选定的审查，作者揭示了这些数据集中的护理数据缺口。美国的护士通过开发护理最小数据集（NMDS）来应对这些数据缺口。NMDS是一种用于从患者记录中提取统一的基本护理数据的工具，通常在出院时使用。NMDS中的护理数据元素包括：护理诊断、护理干预、护理结果和护理强度。在加拿大推动生成NMDS的一个主要因素是回应在维持高质量医疗保健的同时控制不断上涨的医疗保健成本的需求。通过在以下方面使用这些数据，NMDS对所有实践环境中的护士都具有深远影响：护理服务成本核算；为护理资源分配进行辩护；界定护理对患者护理的贡献；界定护理结果；发展护理知识；以及护理作为一门专业的持续发展。加拿大针对NMDS开发的举措表明，人们更加意识到收集、存储和检索护理数据的必要性。然而，加拿大的护士尚未确定纳入加拿大国家卫生信息系统以供使用的基本护理数据元素。
