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

机译：准备护士在电子病历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，护士的教育需要能够在EHR中记录护理诊断，干预措施和患者预后。这项研究的目的是研究“指导临床推理”的效果，“指导临床推理”是一种提高护士使用标准语言能力的学习方法。在一项整群随机实验研究中，来自3个病区的护士接受了临床指导临床指导（GCR），这是一种旨在培养护士陈述护理诊断，相关干预措施和结果的学习方法。接受经典案例讨论的三个病房作为对照组。学习效果通过评估18项Likert型项目（使用“护理诊断，干预和结果的质量”（Q-DIO））以0-4的比例评估18项Likert型项目来评估。使用T检验分析干预前后的得分。 GCR大大提高了护理诊断文档的质量；针对病因的护理干预措施，以及提高护理敏感性患者的治疗效果。在GCR之前，干预前护理文档质量的平均值为2.69（干预后= 3.70； p <.0001）。在护理干预和结果方面发现了相似的结果。在对照组中，质量保持不变。 GCR支持护士陈述准确的护理诊断，选择有效的护理干预措施并提高患者预后的能力。带有相关干预措施和患者结果的护理诊断（NANDA-I）为护士在EHR中使用标准化语言提供了知识库。

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