护理临床决策支持系统用户之间的诊断一致性:一个试点研究
Regina Célia Dos Santos Diogo1, Rita de Cassia Gengo E Silva Butcher2,3, Heloísa Helena Ciqueto Peres1
1School of Nursing, University of São Paulo, São Paulo, Brazil.
概括
这项研究发现使用临床决策支持系统 (CDSS) 的护理诊断一致性较低. 改善临床推理对于在护理实践中有效使用CDSS至关重要.
科学领域:
- 护理信息学 护理信息学
- 临床决策支持系统 临床决策支持系统
- 护理诊断 护理诊断 护理诊断
背景情况:
- 临床决策支持系统 (CDSS) 旨在标准化护理文档.
- 纳达国际,护理干预分类和护理结果分类 (NNN) 分类法为护理诊断提供了一个标准化的框架.
- 评估护理诊断的一致性对于评估CDSS的有效性至关重要.
研究的目的:
- 分析圣保罗大学护理过程电子文档系统 (PROCEnf-USP®) 用户之间的护理诊断一致性.
- 评估在NNN分类结构的特定CDSS中记录的护理诊断中的协议.
主要方法:
- 一项试点,探索性-描述性研究,涉及37名参与者 (护士,住院生,本科生).
- 参与者记录了PROCEnf-USP®中的临床案例研究.
- 护理诊断被提取出来,并使用Light's Kappa分析一致性.
主要成果:
- 在大多数记录的护理诊断中观察到整体不良一致性 (Kappa值从差到中等).
- 像"血糖水平不稳定的风险"这样的特定诊断与其他诊断相比显示出更高的一致性 (K=0.655).
- 一致性仅限于与生物需求相关的三个诊断.
结论:
- 低护理诊断一致性表明临床判断能力,案例研究设计或样本大小存在潜在问题.
- 在护理中有效利用CDSS需要强大的临床推理技能.
- 需要进一步的研究来提高诊断准确性和系统可用性.
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