临床决策支持系统在护理电子病历系统中的应用

Application of Clinical Decision Support Model in Nursing Electronic Medical Record System

分析护理电子病历研究热点与亟待解决的问题,以护理文书为基础,建立以病种库、护理术语数据库、医技信息库、循证信息库为基础的护理辅助决策信息系统数据库。以临床决策支持系统的触发机制与解决方案为技术主线,通过护理术语标准映射、关键字段有效性判定、变异信息处置、护理事件全局管理技术,提升护理病历结构化程度,印证临床决策支持系统对于连续性护理的促进作用,弥补变异数据质量控制的不足,完善质量控制的逻辑判断及预警功能,展现护理病历智能化管理为护理决策所带来的优势。运用时间节点前移,实现问题预先处置,提升护理文书填报质量。

According to Delphi method,based on 8 kinds of nursing documents,the nursing assistant decision-making information system databases based on disease database,nursing terminology database,medical technology information database and evidence-based information database were established respectively;Sort out the problems existing in the writing of nursing documents,take the trigger mechanism and solutions of clinical decision support system under different problem variation degrees as the technical main line,and improve the structural degree of nursing medical records through nursing term standard mapping,key field effectiveness determination,variation information disposal and global management technology of nursing events It confirms that the clinical decision support system promotes continuous nursing,makes up for the deficiency of quality control of variant data,improves the logical judgment and early warning function of quality control,and shows the advantages of intelligent management of nursing medical records for nursing decision-making.The time node forward was used to realize the problem pre-treatment and improve the filling quality of nursing documents.