基于JCI标准的智能化临床护理工作记录框架的构建

Construction of intelligent clinical nursing record framework based on JCI standard

目的建立科学、智能、实用的临床护理工作记录框架。方法以达标理论为指导,结合JCI标准建立的护理记录,初建智能化临床护理工作记录框架;运用德尔菲专家咨询法对来自护理管理、护理教育、临床护理、护理研究等领域的7名专家进行2轮咨询。结果最终确立了1级指标6个、2级指标17个、3级指标80个的标准化和结构化临床护理工作记录的框架。专家咨询的权威系数为0.88,熟悉程度系数为0.79,判断依据系数为0.96;各级指标的协调系数为0.22~0.35。结论智能化电子临床护理工作记录框架,专家咨询意见趋于一致,可信度高,可为临床护理工作提供方便、简洁、实用、高效的记录框架。

Objective To establish a scientific,intelligent and practical clinical nursing record framework. Method The construction of nursing records was based on IMO Jenny.M.gold standard theory and combined with JCI standard. A two-round Delphi consultation was conducted in a judgment sample of 7 experts invited from 4 nursing specialties: nursing management,nursing education,clinical nursing and nursing research. Result The framework for standardized and structured clinical nursing records included 6 primary categories,17 secondary categories and 80 tertiary categories. The authority coefficient of the experts was 0.88. The coefficient of familiarity degree was 0.79,and the coefficient of judgement was 0.96. The Kendall’s W for the indicators was 0.22~0.35. Conclusions The opinion of experts tended to be consistent,and the credibility was high. The intelligent clinical nursing record framework could provide a convenient,concise,practical and efficient record framework for clinical nursing.