结构化护理风险评估与记录系统的构建与应用

Construction and application of the structured nursing risk assessment and recording system

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 quality of nursing records and promote the level of information management.