结构化护理风险评估与记录系统的构建与应用
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摘要
构建具有结构化、信息交互功能、预警提示、临床决策支持功能的护理风险评估与记录系统,其包括护理风险评估模块、护理记录模块、危重患者访视模块、护理交班模块。护士对结构化护理风险评估与记录系统评价较好,认为系统能提高患者安全,利于资料的查询、统计与分析,规范护理行为,提高工作效率,满足临床需求,减少护士笔误。结构化护理风险评估与记录系统有助于提高护理记录的效率和质量,提高护理管理的信息化水平。
We constructed a nursing risk assessment and recording system with structured,interactive information,early warning tips,and clinical decision-support functions. This included a nursing risk assessment module,a nursing record module,a critically ill patient visit module,and a nursing shift module. Nurses thought highly of the risk assessment and recording system,and considered that the system was able to improve patient safety,facilitate data query,statistics and analysis,standardize nursing behavior,improve work efficiency,meet clinical needs,and reduce clerical errors. The structured nursing risk assessment and recording system helped improve the efficiency and qual-ity of nursing records and promote the level of information management.
We constructed a nursing risk assessment and recording system with structured,interactive information,early warning tips,and clinical decision-support functions. This included a nursing risk assessment module,a nursing record module,a critically ill patient visit module,and a nursing shift module. Nurses thought highly of the risk assessment and recording system,and considered that the system was able to improve patient safety,facilitate data query,statistics and analysis,standardize nursing behavior,improve work efficiency,meet clinical needs,and reduce clerical errors. The structured nursing risk assessment and recording system helped improve the efficiency and qual-ity of nursing records and promote the level of information management.
引文
[1]胡文杰,戈艺,李华伟.2016年山东省卫生行业信息化建设分析报告[J].中国数字医学,2017(12):33-35.
[2]李晶.跌倒管理信息系统的建立及应用[J].中华护理杂志,2014,49(1):1347-1350.
[3]孙霁雯,沈南平,吴怡蓓,等.护理措施分类用于儿童心内科护理记录的适用性研究[J].中华护理杂志,2017,52(12):1440-1444.
[4]孙其凤,石兰萍,曹建芬,等.护理记录一体化展现在护理信息系统中的应用研究[J].实用临床护理学杂志,2016,1(11):3-4.
[5]王猛.护理信息系统的应用对护理安全的影响[D].青岛:青岛大学,2013.
[6]周渝霞,于丽莎,郝玉清,等.患者动态评估信息系统研究与设计[J].医院数字化,2011,26(7):53-54,58.
[7]Haeyrinen K,Lammintakanen J,Saranto K.Evaluation of electronic nursing documentation-nursing process model and standardized terminologies as keys to visible and transparent nursing[J].Int J Med Inform,2010,79(8):554-564.
[8]Stevens B.Improving the quality of electronic documentation in critical care nursing[D].Walden:Walden University,2017.
[9]孙霁雯,楼建华,沈南平.护理记录结构化标准化的反思[J].解放军护理杂志,2015,32(23):35-37,40.
[2]李晶.跌倒管理信息系统的建立及应用[J].中华护理杂志,2014,49(1):1347-1350.
[3]孙霁雯,沈南平,吴怡蓓,等.护理措施分类用于儿童心内科护理记录的适用性研究[J].中华护理杂志,2017,52(12):1440-1444.
[4]孙其凤,石兰萍,曹建芬,等.护理记录一体化展现在护理信息系统中的应用研究[J].实用临床护理学杂志,2016,1(11):3-4.
[5]王猛.护理信息系统的应用对护理安全的影响[D].青岛:青岛大学,2013.
[6]周渝霞,于丽莎,郝玉清,等.患者动态评估信息系统研究与设计[J].医院数字化,2011,26(7):53-54,58.
[7]Haeyrinen K,Lammintakanen J,Saranto K.Evaluation of electronic nursing documentation-nursing process model and standardized terminologies as keys to visible and transparent nursing[J].Int J Med Inform,2010,79(8):554-564.
[8]Stevens B.Improving the quality of electronic documentation in critical care nursing[D].Walden:Walden University,2017.
[9]孙霁雯,楼建华,沈南平.护理记录结构化标准化的反思[J].解放军护理杂志,2015,32(23):35-37,40.