摘要
目的 建立和应用基于临床决策支持系统(CDSS)中医护理电子文书质量控制系统,以提升护理质量和效率。方法 将CDSS的理念植入到中医护理文书的设计中,建立中医护理决策支持系统知识库,建立结构化中医护理电子病历,将中医护理结构化电子病历、质量控制系统进行融合。结果 使用CDSS的中医护理电子文书质量控制系统后,系统环节质控合格率由86.5%提高至97%,护理病历完成时间由5.05 h降至2.39 h。结论 基于临床决策支持系统中医护理电子文书质量控制系统保证了中医护理文书书写的规范性、完整性、时效性、时序性,有效提升中医临床护理工作质量。
Objective To establish and apply the quality control system of traditional Chinese medicine nursing electronic documents based on clinical decision support system(CDSS),in order to improve the quality and efficiency of nursing.Methods The concept of CDSS was implanted into the design of Chinese medicine nursing documents,the Chinese medicine nursing decision support system knowledge base was established,the structured Chinese medicine nursing electronic medical records were established,and the Chinese medicine nursing structured electronic medical records and quality control system were integrated.Results After using CDSS’s Chinese medicine nursing electronic document quality control system,the qualified rate of system quality control increased from 86.5%to 97%,and the completion time of nursing records decreased from 5.05 hours to 2.39 hours.Conclusion The quality control system of traditional Chinese medicine nursing electronic documents based on clinical decision support system ensures the standardization,integrity,timeliness and timing of traditional Chinese medicine nursing documents writing,and effectively improves the quality of traditional Chinese medicine clinical nursing work.
作者
郑秀青
刘姝
钟远
任献青
ZHENG Xiuqing;LIU Shu;ZHONG Yuan;REN Xianqing(Nursing Department,the First Affiliated Hospital of Henan University of Traditional Chinese Medicine,Zhengzhou 450000,China;Pediatrics,the First Affiliated Hospital of Henan University of Traditional Chinese Medicine,Zhengzhou 450000,China)
出处
《河南医学研究》
CAS
2023年第22期4161-4165,共5页
Henan Medical Research
基金
河南省卫健委国家中医临床研究基地科研专项(2021JDZY019)。
关键词
临床决策
中医护理
电子文书
质控控制
clinical decision
traditional Chinese medicine nursing
electronic document
quality control
