目的基于临床护理分类系统(clinical care classification,CCC)设计开发结构化电子护理记录系统,并评价其应用价值,为促进护理标准化术语建设提供实证参考。方法基于CCC的框架结构和术语体系,设计开发结构化的电子护理记录系统,并应用...目的基于临床护理分类系统(clinical care classification,CCC)设计开发结构化电子护理记录系统,并评价其应用价值,为促进护理标准化术语建设提供实证参考。方法基于CCC的框架结构和术语体系,设计开发结构化的电子护理记录系统,并应用于重症监护室(intensive care unit,ICU)的临床护理实践。通过分析CCC术语的使用频率、分布特点、护理记录时间等指标,评价其应用效果。结果共使用CCC术语24990条,其中护理诊断5052条、护理措施7443条;176项护理诊断术语中实际使用93项(52.80%)、201项护理措施术语中实际使用108项(53.73%);护士找到所需术语的成功率为89.43%。每次文档录入的平均时间从170.5 s缩短到95.5 s。结论基于CCC的电子护理记录系统能反映ICU护理工作特点及患者病情特点,提高护理记录效率,实现了临床护理信息的标准化表达和数据共享。展开更多
Objectives To explore the challenges of secondary use of routinely collected data for analyzing nursing-sensitive outcomes in Austrian acute care hospitals.Method A convergent parallel mixed methods design was perform...Objectives To explore the challenges of secondary use of routinely collected data for analyzing nursing-sensitive outcomes in Austrian acute care hospitals.Method A convergent parallel mixed methods design was performed.We conducted a quantitative representative survey with nursing managers from 32 Austrian general acute care hospitals and 11 qualitative semi-structured interviews with nursing quality management experts.Both results were first analyzed independently and afterward merged in the discussion.Results On average,76%of nursing documentation is already electronically supported in the surveyed Austrian hospitals.However,existing nursing data is seldom used for secondary purposes such as nursing-sensitive outcome analyses.This is due to four major reasons:First,hospitals often do not have a data strategy for the secondary use of routine data.Second,hospitals partly lack the use of standardized and uniform nursing terminologies,especially for nursing evaluation.Third,routine nursing data is often not documented correctly and completely.Fourth,data on nursing-sensitive outcomes is usually collected in specific documentation forms not integrated into routine documentation.Conclusion The awareness of the possibilities for secondary use of nursing data for nursing-sensitive outcome analyses in Austrian hospitals is still in its infancy.Therefore,nursing staff and nursing management must be trained to understand how to collect and process nursing data for nursing-sensitive outcome analyses.Further studies would be interesting in order to determine the factors that influence the decision-making processes for the secondary use of nursing data for outcome analyses.展开更多
文摘目的基于临床护理分类系统(clinical care classification,CCC)设计开发结构化电子护理记录系统,并评价其应用价值,为促进护理标准化术语建设提供实证参考。方法基于CCC的框架结构和术语体系,设计开发结构化的电子护理记录系统,并应用于重症监护室(intensive care unit,ICU)的临床护理实践。通过分析CCC术语的使用频率、分布特点、护理记录时间等指标,评价其应用效果。结果共使用CCC术语24990条,其中护理诊断5052条、护理措施7443条;176项护理诊断术语中实际使用93项(52.80%)、201项护理措施术语中实际使用108项(53.73%);护士找到所需术语的成功率为89.43%。每次文档录入的平均时间从170.5 s缩短到95.5 s。结论基于CCC的电子护理记录系统能反映ICU护理工作特点及患者病情特点,提高护理记录效率,实现了临床护理信息的标准化表达和数据共享。
文摘Objectives To explore the challenges of secondary use of routinely collected data for analyzing nursing-sensitive outcomes in Austrian acute care hospitals.Method A convergent parallel mixed methods design was performed.We conducted a quantitative representative survey with nursing managers from 32 Austrian general acute care hospitals and 11 qualitative semi-structured interviews with nursing quality management experts.Both results were first analyzed independently and afterward merged in the discussion.Results On average,76%of nursing documentation is already electronically supported in the surveyed Austrian hospitals.However,existing nursing data is seldom used for secondary purposes such as nursing-sensitive outcome analyses.This is due to four major reasons:First,hospitals often do not have a data strategy for the secondary use of routine data.Second,hospitals partly lack the use of standardized and uniform nursing terminologies,especially for nursing evaluation.Third,routine nursing data is often not documented correctly and completely.Fourth,data on nursing-sensitive outcomes is usually collected in specific documentation forms not integrated into routine documentation.Conclusion The awareness of the possibilities for secondary use of nursing data for nursing-sensitive outcome analyses in Austrian hospitals is still in its infancy.Therefore,nursing staff and nursing management must be trained to understand how to collect and process nursing data for nursing-sensitive outcome analyses.Further studies would be interesting in order to determine the factors that influence the decision-making processes for the secondary use of nursing data for outcome analyses.
