基于临床护理分类系统的重症监护室电子护理记录系统的开发与应用

Development and Application of Electronic Nursing Recording System of Intensive Care Units Based on the Clinical Care Classification System

目的基于临床护理分类系统(clinical care classification,CCC)设计开发结构化电子护理记录系统,并评价其应用价值,为促进护理标准化术语建设提供实证参考。方法基于CCC的框架结构和术语体系,设计开发结构化的电子护理记录系统,并应用于重症监护室(intensive care unit,ICU)的临床护理实践。通过分析CCC术语的使用频率、分布特点、护理记录时间等指标,评价其应用效果。结果共使用CCC术语24990条,其中护理诊断5052条、护理措施7443条;176项护理诊断术语中实际使用93项(52.80%)、201项护理措施术语中实际使用108项(53.73%);护士找到所需术语的成功率为89.43%。每次文档录入的平均时间从170.5 s缩短到95.5 s。结论基于CCC的电子护理记录系统能反映ICU护理工作特点及患者病情特点,提高护理记录效率,实现了临床护理信息的标准化表达和数据共享。

Objective To design and develop a structured electronic nursing recording system based on the Clinical Care Classification(CCC)System,and evaluate its application value,so as to provide empirical references for promoting the construction of standardized nursing terminologies.Methods A structured electronic nursing recording system was designed and developed based on the structure and terminology of CCC,and then applied in the clinical nursing practice of intensive care units(ICU).The indicators of usage frequency and distribution characteristics of CCC terminology,as well as recording time were analyzed to evaluate its application value.Results A total of 24,990 CCC terms were used,including 5052 terms of nursing diagnoses and 7443 terms of nursing interventions.Among the 176 terms of nursing diagnoses,93(52.80%)terms were actually used;108(53.73%)terms were actually used among the 201 terms of nursing interventions.The success rate of identifying the required terms was 89.43%.The average time of each record inputting was reduced from 170.5 seconds to 95.5 seconds.Conclusions The electronic nursing recording system based on CCC can reflect the characteristics of ICU nursing work and patients’conditions,improve the efficiency of nursing recording,and achieve the standardized expression of clinical nursing information and data sharing.