标准化护理语言在电子健康记录中的应用现状

Application status of standardized nursing language in electronic health record

电子健康记录是医学信息研究的重要内容,已广泛应用于医疗机构中帮助医疗人员处理各种医疗信息。但由于缺乏标准化护理语言,护士经常无法二次利用电子健康记录中的护理数据,阻碍了医疗信息共享及电子健康记录进一步发展。使用标准化护理语言能够支持电子健康记录中高效完整的护理文档,满足临床与数据的互操作性需求。本文从电子健康记录及标准化护理语言的定义、意义及基于电子健康记录的标准化护理语言应用现状进行综述,以期为国内电子健康记录的发展与完善提供科学参考依据。

Electronic health record is an important part of medical information research and has been widely used in medical institutions to help medical personnel deal with various medical information.However,due to the lack of standardized nursing language,nurses are often unable to reuse nursing data in electronic health records,which hinders the further development of medical information sharing and electronic health records.The use of standardized nursing language can support efficient and complete nursing documents in electronic health records and meet the requirements of clinical and data interoperability.This paper summarizes the definition and significance of electronic health record and standardized nursing language and the application status of standardized nursing language based on electronic health record,so as to provide scientific reference for the development and improvement of electronic health record in China.