Robinson J O, Finch D
Department of Patient Care Services, University of Michigan Medical Center, Ann Arbor, USA.
J Nurs Care Qual. 1997 Aug;11(6):14-25.
The emerging computerized patient record, the movement toward a unified nursing language, and increasing accountability to the public for clinical outcomes are converging forces that require a coherent plan if nursing is to evaluate outcomes. The article describes a nursing service and school of nursing's approach and beginning experiences in identifying concepts and indicators that are useful to clinicians. These concepts and indicators have the potential to be embedded in a concurrent information system that would feed a data repository used retrospectively by clinicians and researchers. The article also discusses results to date and lessons learned.
新兴的计算机化患者记录、向统一护理语言的发展趋势以及公众对临床结果问责制的不断增强，这些力量相互交织，如果护理工作要评估结果，就需要一个连贯的计划。本文描述了一家护理服务机构以及一所护理学院在识别对临床医生有用的概念和指标方面的方法及初步经验。这些概念和指标有可能被嵌入一个同步信息系统中，该系统将为临床医生和研究人员事后使用的数据存储库提供数据。本文还讨论了迄今为止的结果及经验教训。
