電腦護理記錄的基石－－標準化護理語言

Standardized Nursing Language: The Bedrock of Computerized Nursing Records

台灣正值推動護理記錄電子化的起步階段，過去手寫為主的記錄方式要轉換為電子記錄必需透過標準化護理語言，才能達到跨病患、跨科別、跨醫院都能溝通的目標。然而，標準化護理語言對台灣護理界來說，仍屬於新知識，本文介紹了標準化護理語言的定義、意義及重要性與分類系統的關係；也介紹當代致力發展標準化護理語言的兩大主流，美國（國內各護理組織）及國際護理協會所至今所努力的成果，分別為美國護理學會認可的十二種標準語言與國際護理作業分類系統(International Classification for Nursing Practice, ICNP)。台灣已有少部份研究著手測試ICNP與國內現行護理記錄內容轉換的相符性，未來仍需要更多測試與研究。希望本文有助於護理領域成員對標準化護理語言的認識，進而對推動護理記錄電子化有所貢獻。

Taiwan is currently in the initial phase of implementing a nursing information system. In order to successfully achieve effective communications across dispersed and diverse populations, care settings, and locations, standardized language within the nursing profession must be established and promoted. However, standardized nursing language is not well known among Taiwanese nurses. This article introduces the definition of standardized nursing language, the importance of standardized nursing language to the nursing profession, and the relationship between nomenclatures and standardized nursing language. Additionally, twelve language standards recognized by the American Nurse Association and the ICNP (International Classification for Nursing Practice) developed by International Council of Nurses are briefly introduced. In Taiwan, although cross-mapping of ICNP terms with handwritten nursing records has been done, further research must be done to reach practical conclusions. The authors hope this article will help Taiwanese nurses learn more about standardized nursing language and, consequently, contribute more toward the implementation of the nursing information system in Taiwan.