In diesem Artikel beschreibt das Autorenteam um Lundberg die Notwendigkeit einer standardisierten Pflegefachsprache zur Dokumentation des Pflegehandelns.
Mit der Forderung nach Qualtiätssicherung, interner Kontrolle, Effizienz und Kostenkontrolle ist es unerlässlich geworden, das Pflegewissen in einer Form auszuddrücken und zu kommunizieren die es für das ganze Betreuungsteam zugänglich macht (express nursing knowledge in a meaningful way that can be shared across disciplines and care settings).
Die elektronische Pflegedokumentation zeigt die Wirkung des Pflegehandelns innerhalb der gesamten Patientenbetreuung und wertet es damit auf.
Im vorliegenden Artikel werden die von der American Nursing Association anerkannten Terminologien, NANDA, NIC, NOC, Omaha System,
PNDS, and SNOMED CT beschrieben um so den Entscheidungsträgern in der Pflege bei der Auswahl einer für sie geeigneten Terminologie oder auch einer Kombination von Terminologien zu unterstützen.
Introduction
The care nurses provide to sustain life, enable recovery, alleviate suffering and promote health should be captured within the electronic health record (EHR). To share this information between clinical disciplines and care settings, data needs to be recorded and stored in a standardized form. Terminologies are one way to ensure standardization so patient care data can be stored in an
unambiguous way. Nursing has numerous terminologies, each developed for a variety of care settings. Selecting the appropriate nursing terminology
implementation for use in the EHR can be daunting.
This article will highlight selected American Nursing Association’s (ANA recognized nursing terminologies and their relationships to each other. This discussion will assist in making decisions about the combination of nursing terminologies that best fit your organization’s practice and requirements for the EHR.
Zu diesem Thema siehe auch:
Clancy et al.: The Benefits of Standardized Nursing Languages in Complex Adaptive Systems Such as Hospitals. Journal of Nursing Administration. 36(9):426-434, September 2006.
Abstract:
Paperwork is a major source of frustration for hospital nurses and takes valuable time away from patient care. Studies indicate that nurses spend an estimated 13% to 28% of total shift time documenting. The growth in documentation requirements for nurses can, in part, be attributed to an exponential rise in health system complexity. Authors explore the documentation of nursing care plans from a complex adaptive system perspective and then analyze the utility of adopting a standardized nursing language. An actual case history of a nursing unit's attempt to reduce complexity, improve completion time, and increase staff satisfaction in care planning by adopting a standardized nursing language is provided to emphasize a practical application.
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