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Outcome Calculations Based on Nursing Documentation in the First Generation of Electronic Health Records in the Netherlands

机译:基于护理文件的荷兰第一代电子健康记录的结果计算

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Objectives. Previous studies regarding nursing documentation focused primarily on documentation quality, for instance, in terms of the accuracy of the documentation. The combination between accuracy measurements and the quality and frequencies of outcome variables such as the length of the hospital stay were only minimally addressed. Method. An audit of 300 randomly selected digital nursing records of patients (age of >70 years) admitted between 2013-2014 for hip surgery in two orthopaedic wards of a general Dutch hospital was conducted. Results. Nursing diagnoses: Impaired tissue perfusion (wound), Pressure ulcer, and Deficient fluid volume had significant influence on the length of the hospital stay. Conclusion. Nursing process documentation can be used for outcome calculations. Nevertheless, in the first generation of electronic health records, nursing diagnoses were not documented in a standardized manner (First generation 2010-2015; the first generation of electronic records implemented in clinical practice in the Netherlands).
机译:目标。以前关于护理文件的研究主要集中在文档质量上,例如,在文档的准确性方面。精度测量和结果变量的质量和频率之间的组合仅在最小地解决了诸如住院时间的长度。方法。对2013 - 2014年在一般荷兰医院的两个骨科病房中进行了2013-2014的患者的300名随机选择的患者(> 70岁的年龄)审计。结果。护理诊断:组织灌注(伤口)受损,压力溃疡,缺乏流体体积对住院时间的长度有显着影响。结论。护理流程文件可用于结果计算。然而,在第一代电子健康记录中,护理诊断没有以标准化的方式记录(第一代2010-2015;在荷兰临床实践中实施的第一代电子记录)。

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