台灣護理詞彙標準之現況與發展

Nursing Terminology Standards in Taiwan: Current Situation and Trends

郝德慧(Angelica Te-Hui Hao) ； 林秋子(Chiu-Tzu Lin) ； 盧小珏(Shaio-Jyue Lu) ； 林祝君(Zu-Chun Lin)

《護理雜誌》 56卷3期 (2009/06) Pp. 12-17

https://doi.org/10.6224/JN.56.3.12

摘要

護理詞彙對於護理的臨床、教育、行政、研究等專業活動，是不可或缺的溝通依據。另近年來衛生署積極發展電子病歷內容格式(Taiwanelectronic Medical record Template, TMT)，實需要整合護理詞彙標準於相關醫護資訊架構，以適用於各層級機構的醫療資訊系統。本文概述國際間護理詞彙標準及分類系統之發展，與台灣應用部分護理詞彙標準及分類系統於臨床、教育、研究的現況分析。最後為因應現代醫護專業需求，以及配合醫護資訊系統差異性及電子病歷發展趨勢，提出台灣本土化的護理詞彙標準整合應用的建議方向：從護理教育推動與國際護理詞彙標準接軌、以及國際護理詞彙標準本土化整合。期待本文能有拋磚引玉之效用，讓台灣相關護理產官學界重視，將對於台灣護理專業品質更有助益。

關鍵字

護理詞彙 ； 分類系統 ； 護理電子病歷

並列摘要

Nursing terminology standards are critical to effective nursing communications in clinical practice, education, administration, and research. Recently, the national Department of Health has promoted implementation of a standardized Taiwan electronic medical record template (TMT). The TMT provides a specific need for nursing terminology standards used in all medical facilities. In this article, we survey and compare the development of nursing terminology standards in Taiwan with that of the international community. The two principal recommendations made in this paper include 1) link Taiwan terminology standards at the education and research levels to international standards and 2) integrate localized nursing terminology into Taiwan terminology standards for use in nursing information system relational databases and electronic nursing records. We hope that the government, medical institutions, and academic organizations will pay greater attention to the standardization of local nursing terminology in order to advance nursing quality in Taiwan.

並列關鍵字

nursing terminology ； classification ； electronic nursing record