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护理干预词汇表和分类法:对在自动化患者记录中呈现护理数据的影响。

The nursing intervention lexicon and taxonomy: implications for representing nursing care data in automated patient records.

作者信息

Grobe S J

出版信息

Holist Nurs Pract. 1996 Oct;11(1):48-63. doi: 10.1097/00004650-199610000-00009.

DOI:10.1097/00004650-199610000-00009
PMID:8945174
Abstract

The article discusses how the Nursing Intervention Lexicon and Taxonomy (NILT) is being used to describe patterns of care for patients receiving home care nursing. These patterns of care include intensity (frequency of interventions), focus of care (NILT category or categories with the highest percentage of interventions), and comprehensiveness of care (number of NILT intervention categories reflected). Thus with a means for quantifying care in holistic ways, nurses can now ask important questions about clinical care and its outcomes using empirical nursing data about care (i.e., categorized nursing intervention statements). Understanding how these data are expressed using nurses' natural language terms, and being able to categorize these interventions reliably, represent essential preliminary work for describing and defining data for inclusion in the automated record.

摘要

本文讨论了护理干预词汇表和分类法(NILT)如何用于描述接受家庭护理的患者的护理模式。这些护理模式包括强度(干预频率)、护理重点(干预百分比最高的一个或多个NILT类别)和护理全面性(所反映的NILT干预类别的数量)。因此,有了以整体方式量化护理的方法,护士现在可以利用有关护理的实证护理数据(即分类的护理干预陈述),就临床护理及其结果提出重要问题。理解如何使用护士的自然语言术语来表达这些数据,以及能够可靠地对这些干预进行分类,是描述和定义要纳入自动记录的数据的重要前期工作。

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