临床护理分类系统在电子病历中的研究及应用进展
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摘要
临床医疗机构越来越认识到标准化语言是实施电子医疗记录必须的成分。护理信息系统迫切需要应用一种标准化语言,临床护理分类系统为电子健康记录系统中记录患者护理提供了新方法。本文综述临床护理分类系统的形成过程、框架及编码结构以及该系统在电子病历中的研究及应用进展,为后续研究和实践提供借鉴。
Clinical medical institutions are increasingly aware that standardized language is essential for the implementation of electronic medical record. The electronic nursing information system urgently needs to use a standardized language, and the Clinical Care Classification System provides a new method for recording patient care in electronic health record System. This paper reviewed the establishment process, the framework and coding structure and the research and application progress of Clinical Care Classification System. It is expected to provide reference for further study and practice.
Clinical medical institutions are increasingly aware that standardized language is essential for the implementation of electronic medical record. The electronic nursing information system urgently needs to use a standardized language, and the Clinical Care Classification System provides a new method for recording patient care in electronic health record System. This paper reviewed the establishment process, the framework and coding structure and the research and application progress of Clinical Care Classification System. It is expected to provide reference for further study and practice.
引文
[1]蔡卫新,韩丽军,李靖,等.护理电子病历质量审核模块的应用实践.中华护理杂志,2015(1):26-29.Cai WX, Han LJ, Li J, et al. Application of the quality audit module for electronic nursing records.Chinese Journal ofNursing, 2015,50(1):26-29.
[2]石兰萍.智能化护理电子病历的临床应用探讨.中国护理管理,2012,12(10):11-12.Shi LP. Discussion on the clinical application of intelligent nursing electronic medical record.Chinese Nursing Management, 2012,12(10):11-12.
[3]马春丽.护理电子病历发展现状与对策.护理学报,2012,19(4A):17-20.Ma CL. Development status and countermeasures of nursing electronic medical record. Journal of Nursing(China), 2012,19(4A):17-20.
[4]石兰萍.借助信息技术规范护理病历.中国护理管理,2016,16(3):292-294.Shi LP. Standardizing nursing records with information technology. Chinese Nursing Management, 2016,16(3):292-294.
[5] Saranto K, Saba V, Dykes P, et al. Milestones and experiences of standardized documentation.Studies in Health Technology&Informatic, 2016,(225):748-749.
[6] Tastan S, Linch GC, Keenan GM, et al.EvidencefortheexistingAmericanNurses Association-recognized standardized nursing terminologies:a systematic review. International Journal Nursing Studies, 2014,51(8):1160-1170.
[7] Saba VK. Clinical Care Classification(CCC)System, Version 2.5 User's Guide. 2nd ed. Berlin:Springer Publishing Company, 2012.
[8] Saba VK, Taylor SL. Moving past theory:use of a standardized, coded nursing terminology to enhance nursing visibility. Computer, Informatic,Nursing, 2007,25(6):324-331.
[9] Saba VK. Nursing classifications:Home Health Care Classification System(HHCC):an overview. Online Journal of Issues in Nursing,2002,7(3):9.
[10] Kinnunen UM, Junttila K, Liljamo P, et al.FinCC and the National Documentation Model in EHR--user feedback and development suggestions. Studies in Health Technology and Informatics, 2014(201):196-202.
[11]中卫护理信息管理研究院.研究院引入CCC国际术语编码库.(2018-04-03)[2019-03-15].http://www.zweini.org/Nursein Fo-web/page/nurseterms/index.Zhongwei Institude of Nursing Information. The institute introduced CCC international term code base.(2018-04-03)[2019-03-15].http://www.zweini.org/Nursein Fo-web/page/nurseterms/index.
[12] Saba VK.CCC system framework[2018-10-05].https://www.sabacare.com/framework/.
[13]陈颖,冀玉静,孙海霞,等.临床护理分类系统的术语结构、编码构成及应用工具.中华医学图书情报杂志,2018,27(2):75-80.Chen Y, Ji YJ, Sun HX, et al. Term structure, code formation and application tools of the clinical care classification system. Chinese Journal of Medical Library and Information Science, 2018,27(2):75-80.
[14] Saba VK.CCC system Online Code Builder[2018-10-05].http://www.sabacare.com./onlinecode-builder-1/.
[15] Holzemer WL, Henry SB, Dawson C, et al.An evaluation of the utility of the Home Health Care Classification for categorizing patient problems and nursing interventions from the hospital setting. Studies in Health Technology and Informatics, 1997(46):21-26.
[16] Parlocha PK, Henry SB.The usefulness of the Georgetown Home Health Care Classification system for coding patient problems and nursing interventions in psychiatric home care.Computers in Nursing, 1998,16(1):45-52.
[17] Moss JA, Damrongsak M, Gallichio K.Representing critical care data using the clinical care classification.AMIA Annual Symposium Proceedings Archive, 2005(2005):545-549.
[18] Kim H, Dykes PC, Thomas D, et al. A closer look at nursing documentation on paper forms:preparation for computerizing a nursing documentation system. Computers in Biology&Medicine,2011,41(4):182-189.
[19] Englebright J, Aldrich K, Taylor CR.Defining and incorporating basic nursing care actions into the electronic health record. Journal ofNursing Scholarship, 2014,46(1):50-57.
[20] Varzeshnezhad M, Rassouli M, Tafreshi MZ, et al. Transcultural mapping and usability testing of the clinical care classification system for an Iranian neonatal ICU population. Computers,Informatics, Nursing, 2014,32(4):182-188.
[21] Feng RC, Tseng KJ, Yan HF, et al. Capability ofusingclinicalcareclassificationsystem to represent nursing practice in acute setting in Taiwan//American Medical Informatics Association.TheProceedingsofthe11th International Congress on Nursing Informatics.Montreal, 2012:113.
[22] Feng RC, Tseng KJ, Yan HF, et al. A preliminary study on the use of clinical care classification in nursing documentation data sets. Computers Methods and Programs in Biomedcine, 2013,112(3):713-719.
[23] Feng RC, Chang P. Usability of the Clinical Care Classification System for representing nursing practice according to specialty. Computers,Informatics, Nursing, 2015,33(10):448-455.
[24]张红燕,韩琳,张秀娟,等.国外临床护理分类系统的应用现状及启示.中华护理杂志,2018(7):810-812.Zhang HY, Han L, Zhang XJ, et al. Application status and enlightenment of clinical Care classification system overseas. Chinese Journal of Nursing, 2018(7):810-812.
[25] Aslan GK, Emiroglu ON. Evaluation of the applicability of the Clinical Care Classification System to the care of elderly nursing home residents. Computers, Informatics, Nursing, 2013,31(4):178-188.
[26] Whittenburg L, Meetim A. Electronic nursing documentation:patient care continuity using the Clinical Care Classification System(CCC). Studies in Health Technology and Informatics, 2016(225):13-17.
[27] Saranto K, Moss J, Jylha V. Medication counseling:analysis of electronic documentation using the clinical care classification system.Studies in Health Technology and Informatics,2010,160(1):284-288.
[28] Saba VK. Clinical Care Classification System mobile-friendly web tool. Computers, Informatics,Nursing, 2016,34(2):57-59.
[29] Saba VK, Arnold JM. Clinical care costing method for the Clinical Care Classification System. International Journal of Nursing Terminologies and Classifications, 2004,15(3):69-77.
[30] Moss J, Saba V. Costing nursing care:using the clinical care classification system to value nursing intervention in an acute-care setting.Computers, Informatics, Nursing, 2011,29(8):455-460.
[31] Dykes PC, Wantland D, Whittenburg L, et al. A pilot study to explore the feasibility of using the Clinical Care Classification System for developing a reliable costing method for nursing services. AMIA Annual Symposium Proceedings Archive, 2013(2013):364-371.
[32] Lee JY, Park HA. Development and validation of detailed clinical models for nursing actions in perinatal care. International Journal of Medical Informatics, 2017(102):103-110.
[33] Huang H L, Lee CY, Chuang PL, et al. Using model of Clinic Care Classification in clinical nursing information system. Studies in Health Technology and Informatics, 2016(225):1064-1065.
[34] Saba VK, Feeg VD. A bedside PC charting system for nursing students using Clinical Care Classification(CCC)System. AMIA Annual Symposium Proceedings Archive, 2005(2005):1101.
[35] Feeg VD, Saba VK, Feeg AN. Testing a bedside personal computer Clinical Care Classification System for nursing students using Microsoft Access. Computers, Informatics,Nursing, 2008,26(6):339-349.
[36] Mannino JE, Feeg VD. Field-Testing a PC electronic documentation system using the Clinical Care Classification? System with nursing students. Journal of Healthcare Engineering,2015,2(2):223-240.
[37] Hong HS, Lee IK, Cho H, et al. Development of education courseware for clinical Care Classification System based PC and smartphone.Journal of Korean Society for Internet Information,2011,12(3):49-56.
[38]刘霖,Coenen A,陶红,等.国际护理术语分类体系发展概况及其对我国护理的启示.中华护理杂志,2015,50(5):593-597.Liu L, Coenen A, Tao H, et al. The overview ofinternationalclassificationfornursing terminology and its inspiraion to Chinese nursing.Chinese Journal of Nursing, 2015,50(5):593-597.
[39]杜佳敏,谢红.标准化护理语言的应用进展及其应用于养老护理的可行性分析.中华护理杂志,2017,52(7):874-878.Du JM, Xie H. Research progress of standardized language application analysis in nursing care for the elderly. Chinese Journal of Nursing, 2017,52(7):874-878.
[40]孙霁雯,楼建华,沈南平.护理记录结构化标准化的反思.解放军护理杂志,2015,32(23):35-37.Sun JW, Lou JH, Shen NP. Reflection on the structural standardization of nursing records.Nursing Journal of Chinese People's Liberation Army, 2015,32(23):35-37.
[2]石兰萍.智能化护理电子病历的临床应用探讨.中国护理管理,2012,12(10):11-12.Shi LP. Discussion on the clinical application of intelligent nursing electronic medical record.Chinese Nursing Management, 2012,12(10):11-12.
[3]马春丽.护理电子病历发展现状与对策.护理学报,2012,19(4A):17-20.Ma CL. Development status and countermeasures of nursing electronic medical record. Journal of Nursing(China), 2012,19(4A):17-20.
[4]石兰萍.借助信息技术规范护理病历.中国护理管理,2016,16(3):292-294.Shi LP. Standardizing nursing records with information technology. Chinese Nursing Management, 2016,16(3):292-294.
[5] Saranto K, Saba V, Dykes P, et al. Milestones and experiences of standardized documentation.Studies in Health Technology&Informatic, 2016,(225):748-749.
[6] Tastan S, Linch GC, Keenan GM, et al.EvidencefortheexistingAmericanNurses Association-recognized standardized nursing terminologies:a systematic review. International Journal Nursing Studies, 2014,51(8):1160-1170.
[7] Saba VK. Clinical Care Classification(CCC)System, Version 2.5 User's Guide. 2nd ed. Berlin:Springer Publishing Company, 2012.
[8] Saba VK, Taylor SL. Moving past theory:use of a standardized, coded nursing terminology to enhance nursing visibility. Computer, Informatic,Nursing, 2007,25(6):324-331.
[9] Saba VK. Nursing classifications:Home Health Care Classification System(HHCC):an overview. Online Journal of Issues in Nursing,2002,7(3):9.
[10] Kinnunen UM, Junttila K, Liljamo P, et al.FinCC and the National Documentation Model in EHR--user feedback and development suggestions. Studies in Health Technology and Informatics, 2014(201):196-202.
[11]中卫护理信息管理研究院.研究院引入CCC国际术语编码库.(2018-04-03)[2019-03-15].http://www.zweini.org/Nursein Fo-web/page/nurseterms/index.Zhongwei Institude of Nursing Information. The institute introduced CCC international term code base.(2018-04-03)[2019-03-15].http://www.zweini.org/Nursein Fo-web/page/nurseterms/index.
[12] Saba VK.CCC system framework[2018-10-05].https://www.sabacare.com/framework/.
[13]陈颖,冀玉静,孙海霞,等.临床护理分类系统的术语结构、编码构成及应用工具.中华医学图书情报杂志,2018,27(2):75-80.Chen Y, Ji YJ, Sun HX, et al. Term structure, code formation and application tools of the clinical care classification system. Chinese Journal of Medical Library and Information Science, 2018,27(2):75-80.
[14] Saba VK.CCC system Online Code Builder[2018-10-05].http://www.sabacare.com./onlinecode-builder-1/.
[15] Holzemer WL, Henry SB, Dawson C, et al.An evaluation of the utility of the Home Health Care Classification for categorizing patient problems and nursing interventions from the hospital setting. Studies in Health Technology and Informatics, 1997(46):21-26.
[16] Parlocha PK, Henry SB.The usefulness of the Georgetown Home Health Care Classification system for coding patient problems and nursing interventions in psychiatric home care.Computers in Nursing, 1998,16(1):45-52.
[17] Moss JA, Damrongsak M, Gallichio K.Representing critical care data using the clinical care classification.AMIA Annual Symposium Proceedings Archive, 2005(2005):545-549.
[18] Kim H, Dykes PC, Thomas D, et al. A closer look at nursing documentation on paper forms:preparation for computerizing a nursing documentation system. Computers in Biology&Medicine,2011,41(4):182-189.
[19] Englebright J, Aldrich K, Taylor CR.Defining and incorporating basic nursing care actions into the electronic health record. Journal ofNursing Scholarship, 2014,46(1):50-57.
[20] Varzeshnezhad M, Rassouli M, Tafreshi MZ, et al. Transcultural mapping and usability testing of the clinical care classification system for an Iranian neonatal ICU population. Computers,Informatics, Nursing, 2014,32(4):182-188.
[21] Feng RC, Tseng KJ, Yan HF, et al. Capability ofusingclinicalcareclassificationsystem to represent nursing practice in acute setting in Taiwan//American Medical Informatics Association.TheProceedingsofthe11th International Congress on Nursing Informatics.Montreal, 2012:113.
[22] Feng RC, Tseng KJ, Yan HF, et al. A preliminary study on the use of clinical care classification in nursing documentation data sets. Computers Methods and Programs in Biomedcine, 2013,112(3):713-719.
[23] Feng RC, Chang P. Usability of the Clinical Care Classification System for representing nursing practice according to specialty. Computers,Informatics, Nursing, 2015,33(10):448-455.
[24]张红燕,韩琳,张秀娟,等.国外临床护理分类系统的应用现状及启示.中华护理杂志,2018(7):810-812.Zhang HY, Han L, Zhang XJ, et al. Application status and enlightenment of clinical Care classification system overseas. Chinese Journal of Nursing, 2018(7):810-812.
[25] Aslan GK, Emiroglu ON. Evaluation of the applicability of the Clinical Care Classification System to the care of elderly nursing home residents. Computers, Informatics, Nursing, 2013,31(4):178-188.
[26] Whittenburg L, Meetim A. Electronic nursing documentation:patient care continuity using the Clinical Care Classification System(CCC). Studies in Health Technology and Informatics, 2016(225):13-17.
[27] Saranto K, Moss J, Jylha V. Medication counseling:analysis of electronic documentation using the clinical care classification system.Studies in Health Technology and Informatics,2010,160(1):284-288.
[28] Saba VK. Clinical Care Classification System mobile-friendly web tool. Computers, Informatics,Nursing, 2016,34(2):57-59.
[29] Saba VK, Arnold JM. Clinical care costing method for the Clinical Care Classification System. International Journal of Nursing Terminologies and Classifications, 2004,15(3):69-77.
[30] Moss J, Saba V. Costing nursing care:using the clinical care classification system to value nursing intervention in an acute-care setting.Computers, Informatics, Nursing, 2011,29(8):455-460.
[31] Dykes PC, Wantland D, Whittenburg L, et al. A pilot study to explore the feasibility of using the Clinical Care Classification System for developing a reliable costing method for nursing services. AMIA Annual Symposium Proceedings Archive, 2013(2013):364-371.
[32] Lee JY, Park HA. Development and validation of detailed clinical models for nursing actions in perinatal care. International Journal of Medical Informatics, 2017(102):103-110.
[33] Huang H L, Lee CY, Chuang PL, et al. Using model of Clinic Care Classification in clinical nursing information system. Studies in Health Technology and Informatics, 2016(225):1064-1065.
[34] Saba VK, Feeg VD. A bedside PC charting system for nursing students using Clinical Care Classification(CCC)System. AMIA Annual Symposium Proceedings Archive, 2005(2005):1101.
[35] Feeg VD, Saba VK, Feeg AN. Testing a bedside personal computer Clinical Care Classification System for nursing students using Microsoft Access. Computers, Informatics,Nursing, 2008,26(6):339-349.
[36] Mannino JE, Feeg VD. Field-Testing a PC electronic documentation system using the Clinical Care Classification? System with nursing students. Journal of Healthcare Engineering,2015,2(2):223-240.
[37] Hong HS, Lee IK, Cho H, et al. Development of education courseware for clinical Care Classification System based PC and smartphone.Journal of Korean Society for Internet Information,2011,12(3):49-56.
[38]刘霖,Coenen A,陶红,等.国际护理术语分类体系发展概况及其对我国护理的启示.中华护理杂志,2015,50(5):593-597.Liu L, Coenen A, Tao H, et al. The overview ofinternationalclassificationfornursing terminology and its inspiraion to Chinese nursing.Chinese Journal of Nursing, 2015,50(5):593-597.
[39]杜佳敏,谢红.标准化护理语言的应用进展及其应用于养老护理的可行性分析.中华护理杂志,2017,52(7):874-878.Du JM, Xie H. Research progress of standardized language application analysis in nursing care for the elderly. Chinese Journal of Nursing, 2017,52(7):874-878.
[40]孙霁雯,楼建华,沈南平.护理记录结构化标准化的反思.解放军护理杂志,2015,32(23):35-37.Sun JW, Lou JH, Shen NP. Reflection on the structural standardization of nursing records.Nursing Journal of Chinese People's Liberation Army, 2015,32(23):35-37.