临床决策支持系统护理计划模块的设计与研发

Design and development of nursing care planning section of clinical decision support system

目的基于精准护理、数据共享的理念,设计与研发临床决策支持系统护理计划模块,为开发更加智慧化、系统化的护理临床决策支持系统提供参考。方法以护理程序为框架,参考国际护理术语分类体系构建循证知识库;结合临床需求设计护理计划模块,从护理问题、目标、措施及活动的生成、排序和停止三方面制订模块逻辑推理规则,最终形成临床决策支持系统护理计划模块。结果临床决策支持系统护理计划模块包括患者基本信息、阳性评估项及权重值、护理问题、目标、措施及活动等内容;该模块能够依据患者个体特征指标(阳性评估项)自动推导出护理计划,并根据产生时间、权重值、关联度对护理问题及相应的措施和活动进行排序,且能自动判别护理问题、目标、措施和活动停止的时机,实现了智能决策。结论本系统护理计划模块界面清晰,逻辑推理规则严谨,突破了长期以来临床情境下依据个人专业知识及经验进行护理决策的瓶颈,能够保证护理方案的同质化,提高决策的正确性。

Objective To provide reference for the development of a more intelligent and systematic nursing clinical decision support system based on the concept of precision nursing and data sharing,the nursing plan module of clinical decision support system.Methods An evidence-based knowledge base was constructed based on the nursing process and the standardized nursing terminologies;the nursing plan module was designed according to clinical needs,and the logical reasoning rules were formulated from the generation,sequencing and stopping of nursing problems,objectives,measures and activities,and finally the nursing plan module of clinical decision support system was formed.Results The nursing plan module of clinical decision support system included the basic information of patients,positive evaluation items and weight values,nursing problems,objectives,measures and activities,etc.the module could automatically deduce the nursing plan according to the patient's individual characteristic index(positive evaluation item),and sort the nursing problems and corresponding measures and activities according to the generation time,weight value and correlation degree.It could automatically distinguish nursing problems,goals,measures and the time of activity stop,and realize intelligent decision-making.Conclusion The interface of nursing plan module of this system is clear and logical reasoning rules are rigorous.It breaks through the bottleneck of nursing decision-making based on personal professional knowledge and experience in clinical situation for a long time,which can ensure the homogeneity of nursing plan and improve the correctness of decision-making.