基于护理电子病历的临床决策支持系统的设计与应用

Design and application of clinical decision support system based on nursing electronic medical record

目的探讨基于护理电子病历设计临床决策支持系统,在提高护理质量及健康教育效果方面的价值。方法以医疗信息系统(HIS)为护理电子病历系统的支撑平台,硬件平台为掌上电脑(PDA),网络平台为医院无线局域网,植入临床决策支持系统包括量表评估、护理问题、护理计划、执行措施四个主要内容。自2018年1月起将临床决策支持系统植入护理电子病历并进行试用,实施前后分别随机抽取100例住院患者比较疼痛、跌倒、压疮等方面相关护理质量及健康教育效果。结果临床决策支持系统植入护理电子病历后经过1个月培训,试用科室护士均掌握该系统的运用;采用医院常规护理质控标准的评分表进行评价,实施后跌倒预防护理、压疮预防护理、疼痛护理质量评分均显著高于实施前,差异具有统计学意义(P<0.05);饮食护理、用药、检查、疾病康复、出院注意事项知识掌握程度均显著高于实施前,差异具有统计学意义(P<0.05)。结论基于护理电子病历设计临床决策支持系统,使电子病历不仅用于记录护理过程,还可作为强有力的临床护理支持系统,指导护士按照护理程序以问题为导向进行临床护理,指导护士提供同质化、规范化的护理服务,以提高护理及健康教育质量。

Objective To discuss the value of designing a clinical decision support system based on nursing electronic medical records in improving the quality of nursing and health education.Methods The medical information system(HIS)is the supporting platform of the nursing electronic medical record system,the hardware platform is a personal digital assistant(PDA),and the network platform is a wireless local area network in the hospital.The implanted clinical decision support system includes four main contents,scale evaluation,nursing problems,the nursing plan,and implementation measures.Since January 2018,the clinical decision support system has been implanted in the nursing electronic medical record and tested.Before and after the implementation,100 hospitalized patients were randomly selected to compare the quality of care and health education related to pain,falls,pressure ulcers,and other aspects.Results After one month of training that the clinical decision support system was implanted in the nursing electronic medical record,the trial department nurses mastered the application of the system;the evaluation was conducted using the scoring table of the hospital′s routine nursing quality control standards.After implementation,the quality scores of fall prevention nursing,pressure ulcer prevention nursing,and pain nursing were significantly higher than before the implementation,and the difference was statistically significant(P<0.05);after the implementation,diet care,medication,examination,disease rehabilitation,and the degree of knowledge of discharge precautions were significantly higher than those before implementation,and the difference was statistically significant(P<0.05).Conclusion The design of the clinical decision support system based on the nursing electronic medical record design makes the electronic medical record not only used to record the nursing process,but also as a powerful clinical nursing support system,guiding nurses to perform problem-oriented clinical care following nursing procedures,and instructing nurses to provide homogenized and standardized nursing services to improve nursing and health education quality.