奥马哈系统理论[规整].pdf

The Omaha System: A Key to Practice, Documentation, and Information Management 奥⻢哈系统: 实践、⽂档(记录）和信息管理的关键 Karen S. Martin, RN, MSN, FAAN Health Care Consultant Martin Associates Omaha, Nebraska, USA martinks0007@ 1 / 27 Objectives ⺫标 Note global trends involving practice, documentation, and information management •关注实践、记录和信息管理的全球趋势 Describe the structure and terms of the Omaha System •叙述奥⻢哈系统的结构和术语 Summarize Omaha System users •概述奥⻢哈系统的⽤户 2 / 27 Global Trends: 全球趋势 Demands that huge amounts of data are collected and processed, however our information remains largely invisible. It is stored in “data cemeteries”. ⼤量的数据被收集和处理，然⽽我们的信息仍然⼤ 部分不可⻅。被存储在“数据坟墓“ 中 Clinical information IS the strategic tool of the present and future. 临床信息是现在和将来的战略⼯具 We NEED to convert data to information! 我们需要将数据转换为信息! 3 / 27 Global Trends: 全球趋势: MUST document, measure, and communicate their practice outcomes; this is a key to increasing the quality of care. 必须记录、测量、沟通其实践结局，这是提⾼医 护质量的关键 If we cannot name it, we cannot control it, finance it, teach it, research it, or put it into public policy. Norma M. Lang, 1992 如果我们不能命名它，我们就⽆法控制、资助、传授、研 究，或将其纳⼊公共政策“Norma M. Lang, 1992 4 / 27 Vision for the Future—in the 1970s —20 70 展望未来 世纪 年代 • DeLanne Simmons – Practice实践 – Documentation记录 – Information Management 信息管理 • 4 federally-funded research projects (1975-1993) 4项联邦政府资助的研究项⺫ (1975-1993) 5 / 27 6 / 27 Omaha System Characteristics 奥⻢哈系统的特点 • Research/evidence/practice-based • 基于研究/证据/实践 • Public domain • 开放资源 • Standardized, comprehensive terminology • 标准化，全⾯的术语 • Relatively simple and ea