结构化电子病历中护理临床决策支持系统的设计与建设

Design and Construction of Clinical Decision Support for Nursing in Structured Electronic Medical Records

目的:建立智能化的护理临床决策支持系统,以提高临床护理工作的安全、质量及效率。方法:以电子病历成熟度评审标准为指导,通过护理计划、护理常规等知识库的建立,不断完善护理决策支持系统。结果:通过对比,根据工时测算结果,目前护士在护理文书书写时间大大减少,全院每日可节约222.5小时,按每名护士每日工作时间为7小时计算,全院可节约31名护士;护理诊断正确率由使用前的68.33%上升为90.67%。结论:护理临床决策支持系统在节约护理工时、提高护理质量及保障患者安全方面卓有成效,值得在临床推广应用。

Objective: To establish an intelligent clinical decision support system for nursing to improve the safety, quality and efficiency of clinical nursing. Methods: Under the guidance of the review standard of maturity of electronic medical records, the nursing decision support system is continuously improved through the establishment of knowledge base of nursing plan, nursingroutine, etc. Results: By comparison, according to the measurement and calculation results of working hours, at present the time of writing nursing documents by nurses has been greatly reduced. 222.5 hours can be saved in the whole hospital per day, 31 nurses can be saved in the whole hospital according to the working time of each nurse of 7 hours per day;and the accuracy of nursing diagnosis has increased from 68.33% before use to 90.67%. Conclusion: The clinical decision support system for nursing is effective in saving nursing man-hours, improving nursing quality and ensuring patients’ safety. It is worth popularizing and applying in clinical application.