护士视角下的医院护理信息系统现状调查与分析

Investigation and analysis of the current situation of hospital nursing information system from the perspective of nurses

目的从护士视角调查医院护理信息系统发展现状。方法根据护理信息系统特点,自制调查问卷,于2018年5月3—10日在浙江省中卫护理信息管理研究院微信公众号及各类护理管理/信息相关微信群公布在线问卷,自愿参与调查。共有1 966名护士参与调查,有效问卷1 364份。结果全国共有417家医院参与调查,其中三级医院281家,二级医院130家;拥有护理信息系统的三级医院占82.75%,二级医院占65.65%。护理信息系统主要以临床护理信息系统和护理管理信息系统为主。临床护理信息系统"非常满足临床护理需求"的比例为5.21%;护理管理信息系统"非常满足护理管理需求"的比例为1.96%。护理信息系统存在"各分系统无法对接""数据无法提取""需要重复录入数据"等问题。结论我国医院护理信息系统建设比较落后,护理信息系统不能满足临床与管理需求。为建设智慧护理信息系统,急需开展护理标准术语研究。

Objective To investigate the current development of hospital nursing information systems from the perspective of nurses. Methods According to the characteristics of nursing information system, self-made questionnaires were published online from 3rd to 10th May, 2018 in Weixin Subscription Number of Zhejiang Zhongwei Nursing Information Management Research Institute and all kinds of Weixin groups related to nursing management/information. A total of 1 966 nurses volunteered to participate in the survey and 1 364 valid questionnaires were collected. Results A total of 417 hospitals were covered in the survey, including 281 tertiary hospitals and 130 secondary hospitals. 82.75% of the tertiary hospitals and 65.65% of the secondary hospitals had nursing information system. The nursing information systems were mainly based on the clinical nursing information system and the nursing management information system. The proportion of clinical nursing information system "meeting clinical nursing needs very well" was 5.21%. The proportion of "satisfying nursing management needs very well" in nursing management information system was 1.96%. There are some problems in nursing information system, such as "each subsystem can not be docked""data can not be extracted","data need to be re-entered" and so on. Conclusions The construction of hospital nursing information system in China is relatively backward, and nursing information system can not meet the needs of clinical and management. In order to build intelligent nursing information system, it is urgent to carry out research on nursing standard terminology.