基于任务驱动的结构化护理评估系统的构建与应用研究  

Construction and application of task-driven structured nursing assessment system

作　　者：冯璇[1] 周晓美[2] 蒋岩 季瑞杰 李菲菲 刘晔[1] Feng Xuan;Zhou Xiaomei;Jiang Yan;Ji Ruijie;Li Feifei;Liu Ye(Department of Nursing,Qilu Hospital of Shandong University,Qingdao Shandong 266000;Department of Cardiology,Qilu Hospital of Shandong University,Qingdao Shandong 266000;Cardiothoracic Surgery,Qilu Hospital of Shandong University,Qingdao Shandong 266000)

机构地区：[1]山东大学齐鲁医院护理部,山东青岛266000 [2]山东大学齐鲁医院心内科,山东青岛266000 [3]山东大学齐鲁医院心胸外科,山东青岛266000

出　　处：《护士进修杂志》2020年第17期1543-1548,共6页Journal of Nurses Training

基　　金：山东省青岛市医药科研指导计划项目(编号:2018-WJZD130);山东大学齐鲁医院(青岛)护理创新基金(编号:QDKY2016HL01,QDKY2019HL01)。

摘　　要：目的探讨基于任务驱动的结构化护理评估系统的临床效果。方法构建护理评估系统,该系统以护理程序主导的任务驱动为主轴,通过护理评估结构化录入,实现护理信息自动推导,引发护理任务,驱动护士临床执行。比较其应用前后护理文书缺陷率,护理评估用时以及护理评估系统应用效果。结果系统应用后各类护理评估时机、频次不符合要求(χ^2=120.000,P<0.05),文书存在漏项、缺项情况(χ^2=120.000,P<0.05),各类护理表单内容欠统一(χ^2=9.376,P<0.05),文书填写未采用标准化术语(χ^2=4.213,P<0.05),电子体温单绘制漏项或不符合规范(χ^2=120.000,P<0.05)等护理文书缺陷率显著降低;日常评估(t=22.353,P<0.05)与入院评估(t=16.175,P<0.05)用时显著缩短;责任护士的护理实践能力(t=-2.202,P<0.05)、风险管理评价(t=-2.998,P<0.05)有显著性提高。结论基于任务驱动的结构化护理评估系统的应用可降低护理文书缺陷率,缩短护理评估用时,改善临床护士的护理实践能力、风险管理评价,使临床护理工作更加趋于同质化、标准化、智能化,优化了现有护理工作模式。Objective To study the clinical effect of the task-driven structured nursing assessment system.Methods The nursing evaluation system is to construct,which takes the task-driven by nursing program as the main axis.Through the structured input of nursing evaluation,the nursing information is automatically derived,nursing tasks are triggered,and the clinical execution of nurses is driven.The application effect of nursing evaluation system,the rate of nursing document defect and the time of nursing was evaluated and compared before and after the application.The application effect of nursing evaluation system was analyzed.Results After the system was applied,the defect rate of nursing documents was significantly reduced,such as the timing and frequency of all kinds of nursing evaluation did not meet the requirements(χ^2=120.000,P<0.05).There were missing items and missing items in the documents(χ^2=120.000,P<0.05).The contents of all kinds of nursing forms were not unified(χ^2=9.376,P<0.05).Standardized terms were not used in the document filling(χ^2=4.213,P<0.05).The electronic temperature chart is missing or does not conform to the specification(χ^2=120.000,P<0.05).The time required for daily assessment(t=22.353,P<0.05)and admission assessment(t=16.175,P<0.05)was significantly shorter.The nursing practice ability(t=-2.202,P<0.05)and risk management evaluation(t=-2.998,P<0.05)of the nurses were significantly improved.Conclusion The task-driven structured nursing assessment system can reduce nursing documents defect rate,shorten the nursing assessment,improve the nursing practice ability,risk management evaluation of clinical nurses.The clinical nursing will work constantly to develop towards the direction of homogenization,standardization,intellectualization and optimization the existing model of nursing work.

关 键 词：任务驱动 结构化 护理评估系统 信息化 

分 类 号：R471[医药卫生—护理学]