临床护理信息化建设的探索与实践

Exploration and practice of clinical nursing information construction

目的 实现临床护理工作的信息化管理.方法 基于HIS系统数据库研发并应用了临床护理信息系统.结果 实现了体征采集、护理评估、医嘱执行、文书记录以及管道管理等护理工作的信息化记录,优化了临床工作流程,提高了临床护理工作质量和效率;体现了临床工作量统计的科学性、时效性.结论 临床护理信息系统的建设、应用和发展,使护理工作提高到了一个新层次,临床护理工作逐步走向规范化、科学化、信息化.

Objective To achieve the information management in clinical nursing work.Methods Clinical nursing information system has been developed and applied based on data of nursing information system （HIS）. Results The information record of nursing work included vital signs collection,nursing assessment,medical order implementing,documentations,tube management. Clinical nursing information system could optimize clinical workflow and improve the quality and efficiency of clinical nursing work,which reflected the scientificity and timeliness of clinical workload statistics.Conclusions The construction,application and development of clinical nursing information system bring the nursing work to a new level. As a result,clinical nursing work will gradually become standardized,scientific and informationalized.