초기사정을 위한 간호정보조사지의 임상내용 모델 개발 = Development of Detailed Clinical Models of Nursing Information for Initial Assessment

다국어 초록 (Multilingual Abstract)

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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