以护理电子病历为基础的改良早期预警评分信息系统的开发与应用

Development and application of modified early warning score information system based on nursing electronic medical records

目的探讨以护理电子病历为基础的改良早期预警评分（MEWS）信息系统的应用效果。方法选择725例患者为研究对象，按所在病区分为观察组360例和对照组365例。对照组常规按医嘱进行监测记录与观察，观察组在对照组的基础上增加MEWS信息化系统评分，根据得分情况按照《早期预警处理流程》启动不同级别的监护及处理方案。观察观察组患者护理级别及所对应的MEWS评分以及两组患者意外事件发生率、抢救成功率、病死率。结果观察组患者MEWS评分，特级护理MEWS评分最高（6．81±2．19）分，三级护理MEWS评分最低（1．80±0．72）分。观察组患者意外事件发生率低于对照组，抢救成功率高于对照组，差异具有统计学意义（P〈0．05）；观察组病死率低于对照组，但差异无统计学意义（P〉0．05）。结论以护理电子病历为基础的MEWS信息系统的开发可帮助临床医护人员对老年患者进行快速、准确的病情评估，早期识别“潜在危重病”患者，提高患者安全管理水平，保障了患者安全。

Objective To explore the application effect of modified early warning score （MEWS） information system based on nursing electronic medical records. Methods A total of 725 patients were chosen as the research objects, and were allocated to observation group（ n = 360） and control group（ n=365 ） according to their hospitalized wards. Patients in control group received routine monitoring record and observation according to orders while patients in observation group had an extra MEWS information system grading and different levels of care and treatment scheme based on Early Warning Process. Level of patients care and corresponding MEWS score of observation group and incidence of accident, rescue success rate and mortality rate for patients of two groups were observed and compared. Results MEWS of critical care patients of observation group was the highest （6.81 ± 2.19）, while MEWS of tertiary care patients was the lowest （1.80 ± 0. 72）. Accident rate in observation group was obviously lower than the control group, rescue success rate was higher than control group （ P 〈 0.05 ） ; mortality rate of two groups had no difference （ P 〈 0.05 ）. Conclusions On the basis of nursing electronic medical records, development of MEWS information system could help clinical nurses assess elderly patients rapidly and accurately, identify potential critical care patients early, and improve patients safety management to ensure patients safety.