Towards a model based electronic nursing record.

NI 2012 : 11th International Congress on Nursing Informatics, June 23-27, 2012, Montreal, Canada. International Congress in Nursing Informatics (11th : 2012 : Montreal, Quebec) Pub Date : 2012-06-23 eCollection Date: 2012-01-01

Niels Jansen, Tino Bekkering, Alexander Ruber, Erik Gooskens, William T F Goossen

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Abstract

The electronic nursing record (ENR) as part of the larger electronic health record has been discussed for years. Its implementation is not that widespread as often considered. E.g. in the Netherlands, a fraction of hospitals uses it. This paper describes a nurse led project in a Dutch hospital where an electronic nursing record system has been defined, based on requirements analysis, standardization through Detail Clinical Models (DCM), and implementation. Standardization of data with DCM is a method and a format to organize clinical knowledge, concepts, and data elements such that managing and exchanging semantics of data is independent from specific technology. 28 DCM are used in the specifications of the ENR. Using the DCM standards approach and the mapping of data elements to professional terminologies enable a vendor to develop what is needed for quality care, rather then sell a fixed set product.

本刊更多论文

迈向基于模型的电子护理记录。

电子护理记录(ENR)作为更大的电子健康记录的一部分已经讨论了多年。它的实施并不像通常认为的那样广泛。例如，在荷兰，一小部分医院使用它。本文描述了荷兰一家医院护士主导的项目，在该项目中，基于需求分析、通过详细临床模型(DCM)的标准化和实施，定义了电子护理记录系统。使用DCM的数据标准化是一种组织临床知识、概念和数据元素的方法和格式，这样数据语义的管理和交换就独立于特定的技术。28个DCM用于ENR的规格。通过使用DCM标准方法和将数据元素映射到专业术语，供应商可以开发质量护理所需的内容，而不是销售一套固定的产品。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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NI 2012 : 11th International Congress on Nursing Informatics, June 23-27, 2012, Montreal, Canada. International Congress in Nursing Informatics (11th : 2012 : Montreal, Quebec)

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