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首页> 外文期刊>Journal of the American Academy of Nurse Practitioners. >Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner
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Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner

机译：确定门诊护理护士从业人员在电子健康记录中使用标准化护理语言的障碍

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摘要

Purpose: This study identified the perceived user barriers to documentation of nursing practice utilizing standardized nursing language (SNL) in the electronic health record (EHR) by ambulatory care nurse practitioners (NPs). Data Sources: A researcher-developed survey was sent to a randomized sample of ambulatory care NPs in the United States who belonged to the American Academy of Nurse Practitioners (n= 1997). Conclusions: Surveyed ambulatory care NPs placed a higher value on documenting medical care versus nursing care. Only 17% of respondents currently use SNL and 30% believe that SNL is not important or appropriate to document NP practice. Barriers to using SNL in EHRs included lack of reimbursement for nursing documentation, lack of time to document, and lack of availability of SNL in electronic records. Implications for Practice: Respondents identified NP practice as a blend of medical as well as nursing care but NPs have not embraced the current SNLs as a vehicle to document the nursing component of their care, particularly in EHRs. Until these barriers are addressed and discreet data in the form of SNL are available and utilized in the EHR, the impact of the NPs care will be unidentifiable for outcomes reporting.
机译：目的：本研究确定了非卧床护理执业医生（NPs）在电子健康记录（EHR）中使用标准化护理语言（SNL）来记录护理实践的用户障碍。数据来源：一项研究人员开发的调查被发送到属于美国护理从业者学会的美国门诊护理NP的随机样本（n = 1997）。结论：调查过的门诊护理NP在记录医疗保健与护理保健方面具有更高的价值。当前只有17％的受访者使用SNL，而30％的人认为SNL对于记录NP实践并不重要或不适当。在电子病历中使用SNL的障碍包括：护理文件报销不足，记录时间不足以及电子记录中SNL的可用性不足。对实践的影响：受访者将NP实践视为医疗和护理的混合体，但是NP并没有将当前的SNL视为记录其护理的护理手段的工具，尤其是在EHR中。在解决这些障碍并以ENL形式获取和使用SNL形式的谨慎数据之前，NPs护理的影响对于结果报告将无法确定。

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