养老机构长期护理信息系统最小数据集的构建

doi:10.3761/j.issn.1672-9234.2023.04.003

摘要/Abstract

摘要：

目的构建适用于我国的养老机构长期护理信息系统最小数据集。方法通过文献研究、实地观察和访谈、护理记录内容分析等多种方式提取数据元，初拟养老机构长期护理信息系统最小数据集。采用德尔菲法，选取23名专家进行2轮专家咨询确定数据集的结构和内容。结果 2轮专家咨询的有效问卷回收率分别为81%（26/32）和88%（23/26），专家权威系数分别为0.90和0.88，专家协调系数均具有统计学意义（P<0.001）。最终确定养老机构长期护理信息系统最小数据集包含255个数据元，其中基本信息包括5类60个数据元，护理诊断包括6类69个数据元，护理措施包括8类62个数据元，护理结局包括7类64个数据元。结论本研究构建了一个覆盖护理程序步骤和护理范围的养老机构长期护理信息系统最小数据集，为养老机构长期护理服务的专业化和信息化建设提供参考。

关键词: 德尔菲技术, 养老机构, 长期护理, 护理最小数据集

Abstract:

Objective To develop a nursing minimum data set for long-term care services in aged care settings in China. Methods The minimum data set for long-term care services was formulated based on a review of relevant literature，observation of aged care practice，interviews with care staff in a residential aged care institution，and qualitative content analysis of aged care nursing documentation. In the two-round Delphi process，23 experts were invited to assess the data elements in the data set. Results The response rate of the expert consultation questionnaire in the two-round Delphi process was 81% and 88% respectively. The expert authority coefficient of the two-round expert consultations was 0.90 and 0.88 respectively. The coefficient of concordance Kendall’s W for both two consultation were regarded as being statistically significant（P<0.001）. Finally，a minimum data set with 255 data elements were constructed，including 60 nursing history data elements，69 nursing diagnoses，62 nursing interventions，and 64 nursing outcomes. Conclusion The minimum data set for long-term care services in aged care settings in China was established，consisting of comprehensive data elements covering the steps of the nursing process model and a comprehensive care scope. The data set will provide reference for the development of nursing practice and information systems in long-term for aged care settings.

Key words: Delphi Technique, Aged care facilities, Long-term care, Nursing minimum data set

李夕然, 吴晓芬, 苏婷, 梁津, 王丽洁, 王宁. 养老机构长期护理信息系统最小数据集的构建[J]. 中华护理教育, 2023, 20(4): 403-408.

LI Xiran, WU Xiaofen, SU Ting, LIANG Jin, WANG Lijie, WANG Ning. Development of a nursing minimum data set for long-term care services in aged care settings[J]. Chinese Journal of Nursing Education, 2023, 20(4): 403-408.

图/表 1

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