记叙性护理记录在护理研究中的应用。

Hyeoun-Ae Park, Insook Cho, Hee-Jung Ahn
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引用次数: 0

摘要

为了探讨使用基于标准化术语的电子护理记录系统记录的记述性护理记录的有效性,我们进行了三项不同的研究:(1)所需护理时间与实际护理时间之间的差距,(2)压疮护理的实践变化,以及(3)药物不良事件的监测。从韩国一家教学医院的临床数据存储库中提取并分析了在护理点使用标准化护理声明记录的叙述性护理笔记。我们的研究结果是:儿科和老年科的人员需求相对较高;重症监护患者压疮的总发病率为15.0%,不同护理单位对压疮护理的干预措施不同;在接受顺铂治疗的癌症患者中,至少有53.0%的患者出现了一次药物不良事件。基于标准化护理术语的电子护理记录系统使我们能够探索不同研究问题的答案。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Use of narrative nursing records for nursing research.

To explore the usefulness of narrative nursing records documented using a standardized terminology-based electronic nursing records system, we conducted three different studies on (1) the gaps between the required nursing care time and the actual nursing care time, (2) the practice variations in pressure ulcer care, and (3) the surveillance of adverse drug events. The narrative nursing notes, documented at the point of care using standardized nursing statements, were extracted from the clinical data repository at a teaching hospital in Korea and analyzed. Our findings were: the pediatric and geriatric units showed relatively high staffing needs; overall incidence rate of pressure ulcer among the intensive-care patients was 15.0% and the nursing interventions provided for pressure-ulcer care varied depending on nursing units; and at least one adverse drug event was noted in 53.0% of the cancer patients who were treated with cisplatin. A standardized nursing terminology-based electronic nursing record system allowed us to explore answers to different various research questions.

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