摘要
目的基于国际标准护理术语,研发契合临床护理需求的智能护理信息系统,实现临床护理辅助决策,提高护理工作效率与质量。方法遵循模块化、层次化、结构化的设计原则,植入国际标准护理术语临床照护分类系统知识库及编码,以护理程序为架构研发功能模块。结果基于国际标准护理术语的智能护理信息系统包括患者总览、责任护士派班、护理评估、护理诊断、护理计划、护理执行、护理评价、专项护理、护理记录及护理交接班等功能模块,实现了从护理评估、护理诊断、护理计划、护理执行到护理评价的智能导引与辅助决策,护士使用体验良好。结论智能护理信息系统推动了标准护理程序的落地实践,实现了对临床护理工作的智能辅助决策,促进了临床护理同质化。
Objective To design and develop a intelligent nursing information system to meet the needs of clinical nursing based on international standard nursing terminology,so as to realize the auxiliary decision-making of clinical nursing and improve the efficiency and quality of nursing work.Methods Following the design principles of modularity,hierarchy and structure,the knowledge base and coding of the Clinical Care Classification system of international standard nursing terms was implanted,and research and development was carried out with nursing procedures as a functional module framework.Results The intelligent nursing information system based on international standard nursing terminology included patient overview,responsible nurse assignment,nursing evaluation,nursing diagnosis,nursing plan,nursing execution,nursing evaluation,special nursing,nursing record and nursing shift handover.The intelligent guidance and auxiliary decision from nursing assessment,nursing diagnosis,nursing planning,nursing execution to nursing evaluation were realized,and nurses had a good experience in using it.Conclusion The intelligent nursing information system promotes the practice of standard nursing procedures,realizes the intelligent decision-making of clinical nursing work,and promotes the homogenization of clinical nursing.
作者
杨磊
丛培珑
吴玉娟
纪小波
杨中沛
胡娟
李欣
贾鸿璋
YANG Lei;CONG Peilong;WU Yujuan(HeNan Honliv Hospital,Xinxiang,Henan,453400,China;不详)
出处
《中国卫生质量管理》
2024年第7期1-5,共5页
Chinese Health Quality Management
基金
河南省医学科技攻关计划项目(编号:LHGJ20191369)。
关键词
护理信息系统
标准护理术语
智能化
护理程序
护理知识库
循证护理
护理质量
Nursing Information System
Standard Nursing Terminology
Intelligent
Nursing Procedures
Nursing Knowledge Base
Evidence-Based Nursing
Nursing Quality
