基于临床决策支持系统电子护理文书质量控制录入系统的设计与应用  

Design and application of electronic nursing documentation input system based on the quality control concept of Clinical Decision Support System

作　　者：程建平[1] 史婷奇[2] 陆瑶[3] 陈雁[2] 陆巍[2] 丁丽蓉[2] 吕晓凡 CHENG Jianping;-SHI Tingqi;LU Yao;CHEN Yan;LU Wei;DING Lirong;LYU Xiaofan(Gastrointestinal Endoscopy Center Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, 210008, China)

机构地区：[1]南京大学医学院附属鼓楼医院消化内镜中心,南京市210008 [2]南京大学医学院附属鼓楼医院护理部,南京市210008 [3]南京大学医学院附属鼓楼医院普外科,南京市210008 [4]南京大学医学院附属鼓楼医院麻醉手术科,南京市210008

出　　处：《中国护理管理》2018年第7期958-961,共4页Chinese Nursing Management

基　　金：南京鼓楼医院2017年度护理科研课题(ZSC176)

摘　　要：通过建立和应用基于临床决策支持系统(Clinical Decision Support System,CDSS)的电子护理文书质量控制录入系统,将护理记录信息项结构化、建立录入信息决策知识库、嵌入提醒与自动生成护理任务功能,保障了电子护理文书录入的规范性、完整性和连续性,提高了临床电子护理文书质量,同时也可有效地指导护士的临床决策,从而减少护理差错产生。Electronic Nursing DocumentationInPut system based on quality control concept of Clinical Decision Support System （CDSS）, which will improve uniformity, integrality, continuity and quality of clinical electronic nursing documentation through structuring information items in nursing records, creating database for information input decision, inserting remindingfunctions and auto-generating nursing tasks. In clinical practice, the new system ensured the quality of electronic nursing documentation, and instructed nurses effectively in clinical decisions to reduce nursinz mistakes.

关 键 词：护理文书 电子护理文书 临床决策支持 质量控制 应用 

分 类 号：R47[医药卫生—护理学]