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1、The Omaha System: A Key to Practice, Documentation, and Information Management 奥马哈系统: 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 www.omahasystem.org Objectives目标 Note global trends involving practice, documentation, and informatio
2、n 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 叙述奥马哈系统的结构和术语 Summarize Omaha System users 概述奥马哈系统的用户 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 cemete
3、ries”. 大量的数据被收集和处理，然而我们的信息仍然大 部分不可见。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! Global Trends: 全球趋势: MUST document, measure, and communicate their practice outcomes; this is a key to increasin
4、g 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 Vision for the Futurein the 1970s 展望未来20世纪70年代 DeLanne Simmon
5、s 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目 (1975-1993) Omaha System Characteristics 奥马哈系统的特点 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
6、 and easy to learn 相对简单和易于学习 Quantifies practice 量化实践 Omaha System Characteristics 奥马哈系统的特点 Supports critical thinking/best practices 支持批判性思维/最佳实践 Electronic health records (EHRs) at point-of-care 床边电子健康记录 Improves interprofessional collaboration 促进跨专业合作 Diverse users 多元化用户 Promotes interoperability
7、, use of standards 促进互通性和标准使用 Omaha System Model of the Problem Solving Process 奥马哈系统解决问题模型 Copyright: Martin KS. (2005). The Omaha System: A Key to Practice, Documentation, and Information Management (Reprinted 2nd ed.). Omaha, NE: Health Connections Press. 个人，家庭或社区 收集和评估数据 陈述问题 识别入院 问题评估 计划和干预 识别临
8、时 问题评估 评价问题成效 Problem Classification Scheme Domains (4) 领域 (4) Problems (42) 问题 (42) Modifiers (2 sets) 修饰语(2 组) Signs/Symptoms (clusters) 症状/体征 (群) 问题分类表 Skin 皮肤 Modifiers 修饰语 Signs/Symptoms症状/体征 lesion/pressure ulcer 损伤/压疮 rash 皮疹 excessively dry 过度干燥 excessively oily过度油腻 Inflammation 炎症 Pruritus
9、瘙痒 drainage引流 Bruising 淤伤 hypertrophy of nails 指甲肥大 delayed incisional healing切口愈合延迟 other其他 Problem Classification Scheme 问题分类表 Client Assessment 患者评估 皮肤 营养 传染-感染情况 循环 疼痛 神经-肌肉-骨骼 功能 自我照顾 健康照顾督导 Intervention Scheme干预方案 Categories (4) 干预类别(4) Targets (75) 目标(75) Client-Specific Information 患者特定信息 Sk
10、in-Teaching, Guidance, & Counseling皮肤-教育, 指导及咨询 infection precautions (hand washing, disposal of dressings, protect lesion/incision, other)预防感染措 施 (洗手、处理敷料、保护切口或伤口,其它) signs/symptoms-physical (evidence of disease/infection, change in depth/diameter of lesion, control pain, other)症状/体征生理：(疾病/感染证 据，伤口
11、深度/直径的改变、疼痛控制、其它) skin care (prevent breakdown/keep dry, check changed temperature/sensation, other)皮肤护理 (避 免损伤/保持干燥、监测皮肤温度/感觉的变化、其它 ) Intervention Scheme干预方案 Care Provided: Skin 提供的皮肤护理 Intervention Scheme Categories and Targets 干预类别和目标 Number of Interventions 治疗和程序 健康教育、指导与咨询 监测个案管理 Problem Rating
12、 Scale for Outcomes 问题的成效评分 Knowledge (1-5) 认知 (1-5) Behavior (1-5) 行为 (1-5) Status (1-5) 状况(1-5) Skin-Behavior皮肤-行为 1. unwilling to care for surgical incision 不愿意护理手术切口 2. wiling to learn to care for surgical incision 愿意学习护理手术切口 3. attempts to care for surgical incision, but technique is frequently
13、 inappropriate 尝试护理手术切口，但是操作技术常常不合适 4. usually cleanses and dresses surgical incision using appropriate technique 通常能用适当的技术清洁手术切口并更换敷料 5. Consistently cleanses and dresses surgical incision using appropriate technique 总是能用适当的技术清洁手术切口并更换敷料 Problem Rating Scale for Outcomes 问题的成效评分 Communicable/infect
14、ious condition 传染/感染情况 Courtesy of Pamela J. Correll, RN, MS, Public Health Nursing, Bangor ME Users: Current and Future 用户: 现在和未来 Automated users: 22,000 + 自动化用户: 22,000 + interdisciplinary practitioners/clinicians 跨学科从业者/临床医务工作者 Listserv members from 23 countries 23个国家建立邮件讨论组 Minnesota (Practice,
15、Education, Research, Automation) 明尼苏达州 (实践, 教育, 研究和自动化 ) Diversity of users 用户多元化 Users: Continuum of Care 用户: 照护连续体 Community: Home care, hospice, public health, school health 社区：家庭护理、安宁服务、公共卫生、学校卫生 Clinics, nurse-managed centers 诊所、护士管理的健康中心 Acute care and rehabilitation hospital/ long-term care急性和康复医院/长期照护 Care/case management 照护/个案管理 Faith community sites宗教团体 Universities 高校 Use and Users Wong KY (FKY). (2012). Introduction to advanced nursing practice (2nd ed.). Beijing, Peoples Medical Publishing House. (Chinese) 黄金月 . 高级护理实践导论 (第2版). 北京
