RESUMO
Electronic health record is an important part of medical information research and has been widely used in medical institutions to help medical personnel deal with various medical information. However, due to the lack of standardized nursing language, nurses are often unable to reuse nursing data in electronic health records, which hinders the further development of medical information sharing and electronic health records. The use of standardized nursing language can support efficient and complete nursing documents in electronic health records and meet the requirements of clinical and data interoperability. This paper summarizes the definition and significance of electronic health record and standardized nursing language and the application status of standardized nursing language based on electronic health record, so as to provide scientific reference for the development and improvement of electronic health record in China.
RESUMO
Electronic health record is an important part of medical information research and has been widely used in medical institutions to help medical personnel deal with various medical information. However, due to the lack of standardized nursing language, nurses are often unable to reuse nursing data in electronic health records, which hinders the further development of medical information sharing and electronic health records. The use of standardized nursing language can support efficient and complete nursing documents in electronic health records and meet the requirements of clinical and data interoperability. This paper summarizes the definition and significance of electronic health record and standardized nursing language and the application status of standardized nursing language based on electronic health record, so as to provide scientific reference for the development and improvement of electronic health record in China.
RESUMO
Nursing language plays an important role in describing and defining nursing phenomena and nursing actions. There are numerous vocabularies describing nursing diagnoses, interventions, and outcomes in nursing domain. However, lack of a standardized, unified nursing language is considered as a problem for further development of the discipline of nursing. With this background this study was conducted to construct a semantic network based on cross mapping of existing nursing terminologies. specifically NANDA taxonomy I, Omaha system, HHCC. and NIC. which arc recognized as standard terminology by the American Nurses Association. The nursing semantic network was proposed with the cross mapping results based on the UMLS semantic network.