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在三级护理机构的临床信息系统中实施护理结果分类。

Implementing the Nursing Outcomes Classification in a clinical information system in a tertiary care setting.

作者信息

Timm J A, Behrenbeck J G

机构信息

Mayo Medical Center, Department of Nursing, Rochester, MN, USA.

出版信息

J Nurs Care Qual. 1998 Jun;12(5):64-72. doi: 10.1097/00001786-199806000-00010.

Abstract

Implementing Nursing-Sensitive Outcomes Classification (NOC) is consistent with the goal of the Department of Nursing at this tertiary care center to include the Nursing Minimum Data Set in the electronic medical record (EMR). This article describes the implementation and evaluation of the NOC in selected patient care units where a clinical information system is used in conjunction with departmental patient care guidelines. In light of identified limitations, the NOC was determined to be useful and comprehensive as measured by the frequency of its use, the positive feedback by staff, and the minimal additions identified for the classification.

摘要

实施护理敏感结局分类(NOC)与该三级护理中心护理部将护理最低数据集纳入电子病历(EMR)的目标相一致。本文描述了在选定的使用临床信息系统并结合部门患者护理指南的患者护理单元中NOC的实施和评估情况。鉴于已发现的局限性,从使用频率、工作人员的积极反馈以及为该分类确定的最少补充内容来看,NOC被认为是有用且全面的。

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