標準化された看護用語と電子医療記録: 体系的なレビューの二次分析
Luca Bertocchi1,2, Cristina Petrucci3, Vittorio Masotta3
1Hematology Unit, Trieste University Hospital (ASUGI), Piazza dell'Ospitale 1, 34125 Trieste, Italy.
Healthcare (Basel, Switzerland)
|August 28, 2025
まとめ
標準化された看護用語 (SNT) は電子医療記録 (EHR) にますます統合されています. しかし,その使用と影響に関する報告は一貫せず,看護の可視性と結果の測定を妨げています.
科学分野:
- 介護情報学
- 健康情報管理
- 臨床文書
背景:
- 標準化された看護用語 (SNT) は,より良い患者と組織的な結果と関連しています.
- 電子医療記録 (EHR) は看護データの統合に不可欠です.
- EHRにSNTを組み込むことは,医療の質を向上させるのに不可欠です.
研究 の 目的:
- 構造化された看護評価データとドキュメントを EHR に統合することを分析する.
- アメリカン・ナース・アソシエーションが認めている SNT の影響を報告する研究を検証する.
- EHRシステム内のSNTの使用の傾向と不一致を特定する.
主な方法:
- 体系的なレビューから得られた53の主要な研究の二次分析.
- 介護の評価ツール,EHRの使用,信頼性に焦点を当てたデータ抽出
- PubMed,Scopus,CINAHL,OpenGreyで文献を検索する
主要な成果:
- ゴードンの11の機能的健康パターンとNANDA-I診断は頻繁に使用されました.
- 評価ツールとそのEHRの適用に関する不一致な報告
- 過去10年間,看護データを用いた EHR の使用は増加傾向にあるが,信頼性のデータは限られている.
結論:
- EHRにSNTと構造的評価の統合は増加しているが,一貫性がない.
- 標準化されたドキュメントは 看護の可視性と品質の向上を高めることができます.
- 臨床実践と研究における結果の測定を支援するために,報告の改善が必要である.
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