面向临床路径应用的护理决策信息系统应用实践  

Implementation of Nursing Decision Support System Oriented toward Clinical Pathway Application

作　　者：胡彬[1] 马俊[1] 许燕玲[1] 谭申生[1] 郑西川[1] 

机构地区：[1]上海交通大学附属第六人民医院计算机中心,上海200233

出　　处：《医疗卫生装备》2013年第6期44-46,共3页Chinese Medical Equipment Journal

摘　　要：目的:介绍医院临床信息系统建设中护理决策与循证医疗结合方法,以及实现护理临床路径电子化和临床护理决策信息化的应用实践。方法:以循证医疗与优质护理为基础,从患者信息共享与管理,自动护理事件提醒与计划评估,平板计算机、PDA等移动医疗技术在护理提醒、决策分析中的应用3个方面实现护理决策信息化支持功能。结果:实现了决策支持工具与医院临床信息系统的集成和以患者为中心的护理决策支持。结论:以循证医疗为中心的护理决策与临床工作流的集成存在许多困难,其成功取决于医院临床信息系统基础建设。医院需要建立完善的、与医护工作流相一致的循证医疗支持决策分析的临床信息系统框架机制。Objective To illustrate approaches for providing decision support for evidence-based nursing practice, and integrate evidence into clinical information system with examples from the experience at Shanghai No 6 People＇s Hospital. Methods Evidence-based medicine and high-quality nursing were involved in the development of the informatized nursing decision support, which fell into three aspects including patient information sharing and management, automatic alert and nursing plan assessment, and the application of mobile medical technologies such as panel PC and PDA to nursing reminding and decision analysis. Results The integration of decision support tools with hospital clinical information system was realized, along with the patient-centered nursing decision support. Conclusion Efforts to facilitate application of evidence into nursing practice are unlikely to be successful unless the informatics infrastructure is very superior. The approaches presented use a variety of informatics methods to integrate evidence into CIS in a manner consistent with nursing workflow. [Chinese Medical Equipment Journal,2013,34（6） ：44-46]

关 键 词：护理决策系统 循证医疗 临床信息系统 临床路径 

分 类 号：R473[医药卫生—护理学]