Nursing diagnoses focused on universal self-care requisites.
Activities of Daily Living
Electronic Health Records
Focus Groups
Models
Nursing
Nursing Diagnoses
Standardized Nursing Terminology
Journal
International nursing review
ISSN: 1466-7657
Titre abrégé: Int Nurs Rev
Pays: England
ID NLM: 7808754
Informations de publication
Date de publication:
Sep 2021
Sep 2021
Historique:
revised:
01
12
2020
received:
18
03
2020
accepted:
08
12
2020
pubmed:
5
2
2021
medline:
26
11
2021
entrez:
4
2
2021
Statut:
ppublish
Résumé
(1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self-care requisites; (2) to determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing diagnoses syntaxes within the scope of universal self-care requisites. Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals' dependence to ensure self-care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing diagnoses and interventions. A qualitative study using inductive content analysis and focus group: 1. nursing e-documentation content analysis and 2. focus group to explore implicit criteria or insights from content analysis results. From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self-care requisites emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that emerged after a focus group meeting. Results reveal that nursing diagnoses related to universal self-care requisites can emphasize the impairment or potentialities of the individuals performing self-care. It also shows a lack of consensus on nominating the nursing diagnoses of people with a deficit in universal self-care requisites, resulting in different diagnoses to express the same needs. Representation of most relevant nursing diagnoses within the scope of universal self-care requisites. Incorporating standardized language into electronic health records is not enough for improving quality and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in the backend to meet these requirements.
Sections du résumé
AIMS
OBJECTIVE
(1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self-care requisites; (2) to determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing diagnoses syntaxes within the scope of universal self-care requisites.
BACKGROUND/INTRODUCTION
BACKGROUND
Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals' dependence to ensure self-care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing diagnoses and interventions.
METHODS
METHODS
A qualitative study using inductive content analysis and focus group: 1. nursing e-documentation content analysis and 2. focus group to explore implicit criteria or insights from content analysis results.
RESULTS
RESULTS
From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self-care requisites emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that emerged after a focus group meeting.
CONCLUSION
CONCLUSIONS
Results reveal that nursing diagnoses related to universal self-care requisites can emphasize the impairment or potentialities of the individuals performing self-care. It also shows a lack of consensus on nominating the nursing diagnoses of people with a deficit in universal self-care requisites, resulting in different diagnoses to express the same needs.
IMPLICATIONS FOR NURSING PRACTICE
CONCLUSIONS
Representation of most relevant nursing diagnoses within the scope of universal self-care requisites.
IMPLICATIONS FOR HEALTH POLICY
CONCLUSIONS
Incorporating standardized language into electronic health records is not enough for improving quality and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in the backend to meet these requirements.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
328-340Informations de copyright
© 2021 International Council of Nurses.
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