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相关概念视频

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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Guidelines and Strategies for Safe Computer Charting01:18

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The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
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Purpose of Health Records I01:11

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The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
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Standards of Care II01:19

Standards of Care II

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Nurses bear specific legal responsibilities under several federal statutes, including:
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Ethical Standards I01:25

Ethical Standards I

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The American Nurses Association (ANA) created and implemented the first nationally accepted Code of Ethics for Nurses with Interpretive Statements. The Code of Ethics is a living document regularly updated by the ANA and establishes an ethical standard that is non-negotiable for nurses in all roles and settings.
The Code of Ethics provisions outline the nurse's duty to the patient, the healthcare team, the profession, and society. The Code's fundamental principles include advocacy,...
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Role of Communication in the Nursing Process III: Evaluation and Documentation01:08

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A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
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相关实验视频

Updated: Jun 19, 2025

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients
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Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients

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在EMR/EHR中代表护理实践

Evelyn Hovenga1,2

  • 1eHealth Education Pty Ltd, Melbourne, Australia.

Studies in health technology and informatics
|July 25, 2024
PubMed
概括

ISO 18104标准为电子健康记录 (EHR) 提供了一个更新的护理类别结构. 该框架增强了护理实践的代表性,并证明了护理服务在数字健康生态系统中的价值.

科学领域:

  • 护理信息学 护理信息学
  • 卫生信息系统 卫生信息系统
  • 在医疗保健中的标准化.

背景情况:

  • 电子医疗记录 (EMR) 和电子健康记录 (EHR) 需要标准化的结构来表示复杂的护理实践.
  • 现有的系统可能无法充分捕捉护理行动,诊断和结果的细微差别.
  • 对于互操作性和数据分析而言,普遍认可的护理术语的需要至关重要.

研究的目的:

  • 对护理类别结构的ISO 18104技术标准进行审查和改进.
  • 确保在EMR/EHR和数字健康生态系统中最佳地代表护理实践.
  • 为了使标准与当前的信息技术保持一致,并证明护理服务的价值.

主要方法:

  • 对ISO 18104技术标准的审查.
  • 应用ISO标准审查指南.
  • 与ISO成员利益相关者进行商.
  • 开发思维图来可视化护理实践的知识领域.

主要成果:

  • 一个全面的护理实践知识领域模型,以思维图形式呈现.
  • 使用"护理对象类型"类别识别患者组.
  • 承认护士的合作作用.
关键词:
分类结构 类别结构.临床模型 临床模型护理数据 护理数据语义互操作性 语义互操作性术语 术语 术语 术语 术语 术语 术语 术语

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  • 一个结构化的信息模型,包括护理诊断,行动和护士敏感结果.

    • 结论:

    • 更新的ISO 18104类别结构与现代信息技术很好地保持一致.
    • 该标准的采用有助于证明护理服务的价值.
    • 该框架支持对患者旅程和护理实践的概念和逻辑分析.