信息化建设在临床护理程序中的应用  

Developing of information technology system in clinical nursing process

作　　者：孙洋洋[1] 刘凌昕[2] 张桂[1] 张爱琴[3] 孙琳[3] 胡林峰[4] 吕红利[4] 刘云[3] 

机构地区：[1]南京军区南京总医院呼吸内科,210002 [2]南京军区南京总医院中西医结合科,210002 [3]南京军区南京总医院护理部,210002 [4]南京军区南京总医院消化内科,210002

出　　处：《中国护理管理》2012年第2期65-67,共3页Chinese Nursing Management

摘　　要：目的:从评估、诊断、实施、评价等方面完成护理程序信息化建设,促进护理措施的实施,改善临床整体护理实施不佳的状况。方法:依托医院信息化建设的平台,研建护理程序的信息化体系,实践整体护理理念。结果:开发了易于护士操作的临床信息系统平台及精准、全面的护理文书、电子档案体系,大大地提高了护士的护理水平与工作效率。结论:信息化改造是一项系统工程,需要所有人共同努力。应积极引入现代信息科技成果,学习同行先进经验,通过护理信息化的实施,完成护理病历的"简化",并借助信息化这个手段,锻炼和培养护士的临床护理思维能力。Objective： To promote the implementation of nursing measures and improve the clinical holistic care by developing of information technology system in nursing process. Methods： Based on the hospital information platform to develop the information technology system in nursing process. Results： A nurse-friendly and easy to use clinical information system platform, nursing handbooks, and electronic archive system were developed. It improved the nurse＇s working ability and efficency greatly. Conclusion： Developing the information technology system requires everyone＇s efforts. It may increase the nurse＇s critical thinking ability by using the information technology system in nursing process.

关 键 词：信息化 护理程序 

分 类 号：R47[医药卫生—护理学]