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김영란 ( Kim Young-Lan ) - 서울대학교병원 간호부
박현애 ( Park Hyeoun-Ae ) - 서울대학교 간호대학
민열하 ( Min Yul-Ha ) - 서울대학교 간호대학
이명경 ( Lee Myung-Kyung ) - 서울대학교 간호대학
이영지 ( Lee Young-Ji ) - 콜롬비아대학교 간호대학
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Abstract
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Purpose: The purpose of this study is to develop a detailed clinical model for recording initial nursing assessment items, and to test the applicability of the model to facilitate semantic interoperability for sharing and exchanging nursing information.
Methods: First, the researchers extracted items by analyzing initial nursing assessment records. Second, defining characteristics were identified by analyzing nursing records and reviewing the literature. Third, value sets for defining characteristics were identified and types and cardinalities of defining characteristics were defined based on the value sets. Finally, the detailed clinical model was tested through evaluation by experts and comparison with the initial nursing assessment in a clinical setting.
Results: Sixty-one detailed clinical models were developed with 178 defining characteristics and value sets. The experts’ evaluation and comparison with the initial nursing assessment in a clinical setting showed that the detailed clinical model developed in this study was valid.
Conclusion: Use of this detailed clinical model can ensure that the Electronic Health Record contains meaningful and valid information and supports semantic interoperability of nursing information. This use will promote quality in the nursing records and eventually quality of nursing care.
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KeyWords
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정보 공유, 모델, 표준화, 간호 사정, 지식 표현
Information sharing, Model, Standards, Nursing assessment, Knowledge representation
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원문 및 링크아웃 정보
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등재저널 정보
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