贵州省护理信息术语标准化建设的现状调查  

Investigation on the standardization construction of nursing information terminologies in Guizhou Province

作　　者：杨静[1] 冷安明[2] 方茜[1] 罗梅梅[1] 李德婕[1] 蒙婷婷[1] 石磊磊 Yang Jing;Leng Anming;Fang Qian;Luo Meimei;Li Dejie;Meng Tingting;Shi Leilei(Nursing Department,Guizhou Provincial People's Hospital,Guiyang 550002,China;Department of Traditional Chinese Medicine,Guizhou Provincial People's Hospital,Guiyang 550002,China;Emergency Department,Guizhou Provincial People's Hospital,Guiyang 550002,China)

机构地区：[1]贵州省人民医院护理部,贵阳550002 [2]贵州省人民医院中医科,贵阳550002 [3]贵州省人民医院急诊科,贵阳550002

出　　处：《中华现代护理杂志》2023年第15期2016-2021,共6页Chinese Journal of Modern Nursing

基　　金：贵州省卫生健康委科学技术基金(gzwjkj2020-1-223)。

摘　　要：目的调查贵州省护理信息术语标准化建设情况,为构建贵州省标准化护理术语体系提供参考。方法采用便利抽样法,于2021年6月选取贵州省各级医院的153名护理管理者为研究对象,采用自行编制的医院护理信息标准化术语建设现状调查问卷对研究对象进行调查。问卷包括2个部分,第1部分为医院基本情况及护理信息负责人一般资料,第2个部分为护理信息标准化术语建设情况,包括护理电子病历基本数据集、护理电子病历共享文档、护理信息术语互联互通建设3个维度。采用多重线性回归分析护理信息术语标准化建设的影响因素。本研究共发放问卷153份,回收有效问卷148份,问卷有效回收率为96.73%(148/153)。结果148家贵州省医院护理信息标准化术语建设现状调查问卷总分为(102.22±24.42)分,护理电子病历基本数据集维度得分为(60.35±13.32)分,护理电子病历共享文档维度得分为(27.78±19.08)分,护理术语互联互通建设维度得分为(14.08±2.71)分。多重线性回归分析结果显示,医院级别、护理管理者是否接受过术语培训是医院护理信息标准化术语建设得分的影响因素(P<0.05)。结论贵州省医疗机构护理信息术语标准化建设尚处于信息化建设的初级水平,二级医院管理者对护理信息术语标准化建设重视度不够以及护理信息管理者缺乏对标准化护理术语的认知是重要的影响因素。贵州省应建立全省统一的护理术语标准化架构,并组织对各级医院护理管理者进行护理术语相关培训,为提高贵州省医疗机构护理信息术语标准化水平作准备。Objective To investigate the standardization construction of nursing information terminologies in Guizhou Province and provide reference for constructing a standard nursing terminology system in Guizhou Province.Methods Using the convenient sampling method,a total of 153 nursing managers from hospitals at all levels in Guizhou Province were selected as the research objects in June,2021.The research objects were surveyed using a self-developed survey questionnaire on the current status of standardized terminology construction for hospital nursing information.The questionnaire consisted of two parts.The first part was the basic information of the hospital and the general information of the person in charge of nursing information.The second part was the construction of standardized terminology for nursing information,including three dimensions,such as the basic dataset of nursing electronic medical records,the shared document of nursing electronic medical records and the construction of nursing information terminologies interconnection.Multiple linear regression analysis was used to analyze the influencing factors of standardized construction of nursing information terminologies.A total of 153 questionnaires were distributed in this study and 148 valid questionnaires were collected,with an effective response rate of 96.73%(148/153).Results The total score of the survey questionnaire on the standardization of nursing information terminologies construction in 148 hospitals in Guizhou Province was(102.22±24.42).The basic dataset dimension score of nursing electronic medical records was(60.35±13.32),the shared document dimension score of nursing electronic medical records was(27.78±19.08)and the dimension score of nursing terminology interconnection construction was(14.08±2.71).The results of multiple linear regression analysis showed that hospital level and whether nursing managers had received terminology training were the influencing factors for the score of hospital nursing information standardization terminolog

关 键 词：横断面研究 信息化 护理术语 标准化 问卷调查 

分 类 号：R47[医药卫生—护理学]