关键词: Categorial structure Clinical Models Nursing Data Semantic Interoperability Terminology

Mesh : Electronic Health Records Nursing Informatics Humans Nursing Process Standardized Nursing Terminology Nursing Records Nursing Care Practice Patterns, Nurses'

来  源:   DOI:10.3233/SHTI240156

Abstract:
OBJECTIVE: Review of the ISO 18104 technical standard for a Nursing Categorial structure to best represent nursing practice in EMR/EHRs and digital health ecosystems.
METHODS: Application of ISO standard review guidelines in consultation with ISO member stakeholders.
RESULTS: Comprehensive views of the nursing practice knowledge domain are presented as mindmaps. Groups of patients can now be identified using the \'type of subject of care\' category. The collaborative role of nurses is now recognized. This high level structured information model recognises nursing diagnosis, nursing actions and nurse sensitive outcomes relative to other categories and sub-categories known to influence nursing actions and nurse sensitive outcomes.
CONCLUSIONS: This nursing practice framework reflects the nursing process. It supports conceptual and logical analysis of patient journey related nursing practice.
CONCLUSIONS: This updated categorial structure is a good fit with today\'s information technologies. Its adoption enables the value of nursing services provided to be demonstrated.
摘要:
目的:审查ISO18104护理类别结构技术标准,以最好地代表EMR/EHR和数字健康生态系统中的护理实践。
方法:与ISO成员利益相关者协商后应用ISO标准审查指南。
结果:护理实践知识领域的综合观点作为思维导图呈现。现在可以使用“护理对象类型”类别来识别患者组。现在,护士的协作作用已得到认可。这种高水平的结构化信息模型识别护理诊断,相对于其他已知会影响护理行动和护士敏感结局的类别和子类别,护理行动和护士敏感结局。
结论:该护理实践框架反映了护理过程。它支持与患者旅程相关的护理实践的概念和逻辑分析。
结论:这种更新的分类结构非常适合当今的信息技术。它的采用使所提供的护理服务的价值得到证明。
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