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Preparing Nurses to Use Standardized Nursing Language in the Electronic Health Record

机译：准备护士在电子健康记录中使用标准化的护理语言

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Research demonstrated nurses' education needs to be able to document nursing diagnoses, interventions and patient outcomes in the EHR. The aim of this study is to investigate the effect of Guided Clinical Reasoning, a learning method to foster nurses' abilities in using standardized language. In a cluster randomized experimental study, nurses from 3 wards received Guided Clinical Reasoning (GCR), a learning method to foster nurses in stating nursing diagnoses, related interventions and outcomes. Three wards, receiving Classic Case Discussions, functioned as control group. The learning effect was measured by assessing the quality of 225 nursing documentations by applying 18 Likert-type items with a 0-4 scale of the measurement instrument "Quality of Nursing Diagnoses, Interventions and Outcomes" (Q-DIO). T-tests were applied to analyze pre-post intervention scores. GCR led to significantly higher quality of nursing diagnosis documentation; to etiology-specific nursing interventions and to enhanced nursing-sensitive patient outcomes. Before GCR, the pre-intervention mean in quality of nursing documentation was = 2.69 (post-intervention = 3.70; p < .0001). Similar results were found for nursing interventions and outcomes. In the control group, the quality remained unchanged. GCR supported nurses' abilities to state accurate nursing diagnoses, to select effective nursing interventions and to reach enhanced patient outcomes. Nursing diagnoses (NANDA-I) with related interventions and patient outcomes provide a knowledgebase for nurses to use standardized language in the EHR.
机译：研究表明护士教育需要能够在EHR中记录护理诊断，干预和患者结果。本研究的目的是探讨指导临床推理，学习方法促进护士能力的效果，使用标准语言。在一组随机实验研究中，来自3个病房的护士接受了引导临床推理（GCR），一种学习方法，用于培养护理陈述护理，相关干预和结果。三个病房，接受经典案例讨论，用作对照组。通过使用具有0-4个测量仪器“护理诊断，干预和结果”（Q-DIO）的测量仪器的0-4级奖励类型项目来评估225名护理文件的质量来测量学习效果。应用T检验以分析术后干预评分。 GCR导致了高质量的护理诊断文件;对病原学的护理干预措施和增强护理敏感患者结果。在GCR之前，护理文件质量的前干预意味着= 2.69（干预后= 3.70; P <.0001）。发现了类似的结果用于护理干预和结果。在对照组中，质量保持不变。 GCR支持护士的能力，使诊断准确的护理诊断，选择有效的护理干预，并达到增强的患者结果。有关干预措施和患者结果的护理诊断（NANDA-I）为护士提供了一种在EHR中使用标准语言的护士知识库。

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