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Objective To develop a real-time electronic nursing records quality control system based on No.1 Military Medical Project to solve the existing problems in range,representativeness of detection results,information feedback,information storage and etc.Methods An integrated platform was implemented for information acquisition,integration and display on the bases of No.1 Military Medical Project as well as the interfaces with information management systems for electronic nursing records,clinical laboratory examination,medical examination,imaging and etc,which had the functions of auto monitoring of timeliness and logic of electronic nursing records,manual quality control of the connotation as well as the feedback,statistics and analysis on the problems.Results The system behaved well in stability,compatibility,and could be used for real-time and dynamic control of electronic nursing records,timely information feedback and statistical analysis.Conclusion The system contributes to the quality control of electronic nursing records,and is of great significance for its enhancement.
RESUMO
OBJECTIVES: This study explored the reuse of data captured by nurses to support nursing decisions related to pressure-ulcer care. METHODS: To examine the existence of coded data in an electronic nursing record system for the identified concepts, we used the electronic nursing documents of a teaching hospital in Gyeonggi-Do, in Korea. A surgical intensive care unit (SICU) was selected as the test unit due to the high incidence of pressure ulcers. The concepts were identified from literature review and refined through the involvement of staff nurses. RESULTS: We found that 93.4% of the necessary concepts were matched semantically with data items at the input level of the electronic medical record system. Eighteen concepts (60%) were directly matched with the data variables of structured electronic nursing records. Five concepts (16.7%) were matched into more than two items. Including the standard nursing statements coded in Nurses' notes, five concepts were mapped more. CONCLUSIONS: More than 90% of the concepts were matched successfully, which suggests that the secondary use of the routine data collected in an EMR system could be used to develop an automated risk assessment tool for pressure ulcers.