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相关概念视频

Flow Sheet01:17

Flow Sheet

2.5K
Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
2.5K
Nursing Clinical Information System01:27

Nursing Clinical Information System

1.2K
Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
1.2K
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

1.8K
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
1.8K
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

1.4K
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
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Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

1.6K
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
1.6K
Data Reporting and Recording01:24

Data Reporting and Recording

5.3K
Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
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相关实验视频

Updated: Jan 8, 2026

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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探索护理流表数据的共同数据模型覆盖范围:使用SNOMED CT和LOINC映射的试点研究.

Robin Austin1, Malin Britt Lalich1,2, Katy Stewart2

  • 1School of Nursing, University of Minnesota, Minneapolis, MN 55455, United States.

JAMIA open
|December 16, 2025
PubMed
概括
此摘要是机器生成的。

将护理数据映射到国家共同数据模型 (CDM) 中显示了进展,但突出了挑战. 在将护理流表数据集成到CDM中仍然存在重大差距,限制大规模使用以改善患者护理和研究.

关键词:
一个共同的数据模型.电子健康记录是电子健康记录.评估研究是评估研究.护理信息学 护理信息学护理记录 护理记录

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科学领域:

  • 医疗信息学 医疗信息学
  • 护理信息学 护理信息学
  • 数据标准 数据标准

背景情况:

  • 护理数据,通常记录在流程表中,对整合到标准化的健康数据系统提出了独特的挑战.
  • 共同数据模型 (CDM) 对数据互操作性和大规模健康研究至关重要,但它们对护理特定信息的覆盖面需要评估.
  • 之前的研究已经强调了需要框架来评估CDM中各种临床数据的表现.

研究的目的:

  • 评估护理数据的内容覆盖范围,特别是流表信息,在公开可用的共同数据模型 (CDM) 中.
  • 评估护理流表概念和价值在多大程度上可以映射到标准化术语,如SNOMED CT和LOINC在CDM内.
  • 确定在国家CDM框架内代表护理数据的差距和挑战.

主要方法:

  • 进行了一项映射研究,遵循4个步骤的过程:确定CDM,定义评估标准,映射护理流程表数据,并应用评估标准.
  • 护理流表概念和值被映射到医疗临床术语系统化命名法 (SNOMED CT) 和逻辑观察标识符名称和代码 (LOINC) 中的目标代码.
  • 记录了每个概念和每个价值的映射时间,以了解过程中所涉及的努力.

主要成果:

  • 超过65%的护理流表概念和56%的值成功地映射到SNOMED CT和LOINC目标代码.
  • 绘制一个概念的平均时间比绘制一个值 (0.64 分钟) 长得多 (1.19 分钟).
  • 该研究表明,在绘制护理数据方面取得了进展,但也揭示了实现全面覆盖的持续挑战.

结论:

  • 这项映射研究揭示了在将护理数据整合到国家CDM中存在重大差距,这影响了在规模上利用这些数据的能力.
  • 需要进一步全面地图化努力,以提高CDM中护理数据的实用性,用于研究,政策和临床实践.
  • 解决这些差距可以改善实时患者洞察力,支持基于证据的护理实践,并优化护士敏感的患者结果.