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Implementation of a Next-Generation Electronic Nursing Records System Based on Detailed Clinical Models and Integration of Clinical Practice Guidelines / 대한의료정보학회지
Article em En | WPRIM | ID: wpr-11264
Biblioteca responsável: WPRO
ABSTRACT

OBJECTIVES:

The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system.

METHODS:

A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system.

RESULTS:

The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines.

CONCLUSIONS:

An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
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Texto completo: 1 Base de dados: WPRIM Assunto principal: Semântica / Trigêmeos / Registros de Enfermagem / Sistemas Computadorizados de Registros Médicos / Enfermagem / Prática Clínica Baseada em Evidências / Seul / Confiabilidade dos Dados / Coreia (Geográfico) Tipo de estudo: Guideline / Prognostic_studies Aspecto: Implementation_research Limite: Humans País/Região como assunto: Asia Idioma: En Revista: Healthcare Informatics Research Ano de publicação: 2013 Tipo de documento: Article
Texto completo: 1 Base de dados: WPRIM Assunto principal: Semântica / Trigêmeos / Registros de Enfermagem / Sistemas Computadorizados de Registros Médicos / Enfermagem / Prática Clínica Baseada em Evidências / Seul / Confiabilidade dos Dados / Coreia (Geográfico) Tipo de estudo: Guideline / Prognostic_studies Aspecto: Implementation_research Limite: Humans País/Região como assunto: Asia Idioma: En Revista: Healthcare Informatics Research Ano de publicação: 2013 Tipo de documento: Article