肿瘤专科医院造口患者信息管理系统的构建与实施

Establishment and implementation of management information system for patients with stomas in cancer special hospital

目的基于医院信息系统, 构建造口患者信息管理系统并实施。方法依托北京大学肿瘤医院暨北京市肿瘤防治研究所医院信息系统资源, 根据造口患者的全程信息管理需求, 2018年8月起由护理部与信息中心共同设计研发以造口患者全程管理为主线的信息管理系统, 并在全院临床科室及造口门诊推广使用。结果构建了包含造口新建、造口护理、并发症处理以及造口还纳在内的造口患者全程信息管理系统;2019年5月至2020年10月应用于全院临床科室及造口专科门诊, 涉及全院12个科室, 收治造口患者326例, 累计就诊6 358例次;造口及周围皮肤并发症患者28例, 并发症发生率8.59%(28/326)。结论造口患者信息管理系统的构建实现了对造口患者从造口新建、造口护理、并发症处置乃至造口还纳的全程管理, 为护理人员及时、准确实施专业护理提供依据与指引, 也为持续提升造口护理质量提供依据。

Objective To establish and implement a management information system for patients with stomas based on the hospital information system.Methods Relying on information system resources of Beijing Cancer Hospital,Beijing Institute for Cancer Research,the management information system for patients with stomas was developed by the Nursing Department and the Information Center from August 2018 according to the requirement of whole process management for patients with stomas.Results A whole process management information system was constructed for patients with stomas including stoma construction,stoma care,management of complications and stoma closure.It was applied to 12 departments covering clinical departments and stoma clinics of the hospital,including 326 cases with stomas and 6358 cumulative visits.28 cases with skin complications around stoma were detected and the rate of complications was 8.59%(28/326)from May 2019 to October 2020.Conclusions The management information system for patients with stomas can realize the whole-process management from stoma construction,stoma care,management of complications to stoma closure,and provide basis and guidance for nursing staff to implement professional nursing timely and accurately,which can also provide basis for continuously improving the quality of stoma care.