健康信息学

[中文适用范围]： 本文件规定了代表护理实践的分类结构的特征。本文件的总体目标是支持信息系统之间在护理诊断、护理行动和护士敏感结果方面交换有意义的信息的互操作性。护理诊断、护理行动、护士敏感结果和相关类别的分类结构通过提供通用框架来支持互操作性，这些框架可用于 a) 分析不同术语的特征，包括前后协调表达、其他医疗学科的特征，并确定它们之间的关系性质，[3][4][5][6][7][8] b) 开发用于表示护理诊断、护理行动[9][10][11][12]和护士敏感结果的术语，c) 开发能够相互关联的术语，[3][8][13] 和 d) 建立术语模型、信息模型（包括原型）和护理领域本体之间的关系。[14][15][16][45]早期证据表明，分类结构可用作分析护理实践的框架[17]，用于开发电子记录系统的护理内容[18][19]，记录所提供的护理服务的价值，并使护理的贡献显而易见[16][36][47][50]。 [外文原描述]： This document specifies the characteristics of categorial structures, representing nursing practice. The overall aim of this document is to support interoperability in the exchange of meaningful information between information systems in respect of nursing diagnoses, nursing actions and nurse sensitive outcomes. Categorial structures for nursing diagnoses, nursing actions, nurse sensitive outcomes and associated categories support interoperability by providing common frameworks with which to a) analyse the features of different terminologies, including pre- and post-coordinated expressions, those of other healthcare disciplines, and to establish the nature of the relationship between them, [ 3 ][ 4 ][ 5 ][ 6 ][ 7 ][ 8 ] b) develop terminologies for representing nursing diagnoses, nursing actions, [ 9 ][ 10 ][ 11 ][ 12 ] and nurse sensitive outcomes, c) develop terminologies that are able to be related to each other, [ 3 ][ 8 ][ 13 ] and d) establish relationships between terminology models, information models, including archetypes, and ontologies in the nursing domain. [ 14 ][ 15 ][ 16 ][ 45 ] There is early evidence that the categorial structures can be used as a framework for analysing nursing practice, [ 17 ] for developing nursing content of electronic record systems, [ 18 ][ 19 ] document the value of nursing services provided and to make nursing’s contribution visible [ 16 ][ 36 ][ 47 ][ 50 ] .