【摘要】 目的探讨基于护理质量敏感指标构建临床护理信息数据元,达到护理信息标准化与共享。方法通过对压疮、坠床或跌倒、非计划性拔管、约束具的使用、导尿管相关性尿路感染等10项护理质量敏感指标有关的护理表单及文书分析,采用"自上向下"与"自下而上"相结合的方式,构建护理信息数据元。结果初步提取856项数据元,其中约17.87%(n=153)的数据元已在国家或行业标准被规范,约17.76%(n=152)数据元的某些属性在国家、行业标准被规范,其余64.37%(n=551)的数据元未在任何标准中被规范。结论基于护理质量敏感指标构建的临床数据元能为护理质量的信息交换共享和数据统计分析作桥梁,为临床护理信息数据元标准提供示范案例,为提升护理服务质量和质量管理奠定基础。更多还原

【Abstract】 Objective To explore the clinical nursing information data element based on nursing quality sensitive index,to standardize and share nursing information.Methods Nursing form and instrumental analysis were used to analyze 10 nursing quality sensitive indexes such as pressure sore,falling bed or fall,unplanned extubation,restraint,catheter urinary tract infection,and so on.And bottom-up combined with top-down way was used to build care information data element.Results The preliminary extraction of 856 data elements,of which about 17.87%(n=153)data elements have been specified in the national or industry standard,about 17.76%(n=152)data elements of certain attributes in the country,industry standards are regulated,The remaining 64.37%(n=551)data elements are not specified in any standard.Conclusion The clinical data elements based on nursing sensitive quality index can be used as a bridge for the exchange of information and the statistical analysis of data quality,and provide a demonstration case for clinical nursing information data meta-standard,which lays the foundation for improving nursing service quality and quality management.更多还原