评估结构化文本和模板在门诊护理中的影响。
Evaluating the impact of structured text and templates in ambulatory nursing.
作者信息
Crist-Grundman D, Douglas K, Kern V, Gregory J, Switzer V
机构信息
Oceania Inc., Palo Alto, CA, USA.
出版信息
Proc Annu Symp Comput Appl Med Care. 1995:712-6.
This evaluation looks at the use of templates for entering structured text nursing notes that generate both a legal text note that is the chart record and an underlying coded form of the note to support analysis and research. This study reflects the first phase of a prototype project of an integrated, computerized health record. Templates are notes that have been prewritten using a standard clinical vocabulary. Templates can be used as the basis of a new clinical note and can be either signed unchanged or modified to represent variations in clinical presentation. The prototype setting is a Primary Care clinic where both physicians and nurses are using the computer to enter clinical notes. In the prototype clinic team, nursing utilized the CPR for 100% of all documentation from day one. Use of templates was found to be the most frequent method of initiating a note.
本评估着眼于使用模板来录入结构化文本护理记录，这些记录会生成一份作为病历记录的法定文本记录以及该记录的基础编码形式，以支持分析和研究。本研究反映了一个集成化计算机化健康记录原型项目的第一阶段。模板是使用标准临床词汇预先编写的记录。模板可作为新临床记录的基础，既可以原封不动地签署，也可以进行修改以体现临床表现的差异。原型设置是一家基层医疗诊所，医生和护士都在使用计算机录入临床记录。在原型诊所团队中，从第一天起，护理人员对所有文档都100%使用了CPR。使用模板被发现是开始记录最常用的方法。
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