Implementation of a Next-Generation Electronic Nursing Records System Based on Detailed Clinical Models and Integration of Clinical Practice Guidelines / 대한의료정보학회지
Healthcare Informatics Research
; : 301-306, 2013.
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.Palavras-chave
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