基于临床决策支持的智慧护理系统建设与应用  

Construction and application of a smart nursing system based on clinical decision support

作　　者：王泽阳[1] 张玉洁 孙婕[1] 贾圆圆 邢冀娟[1] 孙素娟[1] 刘新平[1] 李立杰[1] Wang Zeyang;Zhang Yujie;Sun Jie;Jia Yuanyuan;Xing Jijuan;Sun Sujuan;Liu Xinping;Li Lijie(Hebei General Hospital,Shijiazhuang 050000,Hebei Province,China)

机构地区：[1]河北省人民医院,石家庄050000

出　　处：《中国数字医学》2022年第7期111-115,共5页China Digital Medicine

基　　金：河北省医学科学研究重点课题计划项目(20190344)。

摘　　要：目的:搭建基于临床决策支持的智慧护理系统,实现护理程序管理,提高护理专业化、循证化水平,提升护理质量及效率、降低护理风险。方法:通过知识库建设,以“评估-诊断-计划-措施-评价”护理程序为框架,利用智能风险评估、护理任务导向性管理、数据一元化管理等模式,借助移动终端、5G等手段,将临床决策支持系统融入护理流程。对比系统上线前后护士每日书写护理文书的时长,每日护理任务完成率,护理病历的及时率、正确率,每月护理不良事件发生情况,评价智慧护理系统的应用效果。结果:智慧护理系统上线后,护士每日书写护理文书的时长缩短、科室每月护理不良事件数量下降,每日护理任务完成率、护理病历的及时率、正确率均明显提高,差异具有统计学意义(P<0.001)。结论:基于高级临床决策知识库的智慧护理系统的建设,实现向以患者为中心、以护理程序为核心的责任制、循证护理模式转变,提高了护理质量与效率,保障患者安全。Objective To build a smart nursing system based on clinical decision support, realize nursing procedure management, improve nursing specialization and evidence-based level, improve nursing quality and efficiency, and reduce nursing risks. Methods Through the construction of knowledge base, with the nursing procedure framework of "assessment-diagnosis-plan-measure-evaluation", by using intelligent risk assessment, nursing task-oriented management, unified data management and other modes, the clinical decision support system was integrated into the nursing process by mobile terminal, 5 G and other means. The application effect of the smart nursing system was compared by the changes in the daily duration of writing nursing paperwork by nurses, the completion rate of daily nursing tasks, the timeliness and accuracy rate of nursing medical records, and the monthly occurrence of adverse nursing events before and after launching the system. Results After the smart nursing system was launched, the daily duration of writing nursing paperwork by nurses was shortened, the monthly nursing adverse events in the department was decreased, and the completion rate of daily nursing tasks and the timeliness rate and accuracy rate of nursing medical records were significantly improved, with statistical significance(P <0.001). Conclusion The construction of a smart nursing system based on the advanced clinical decision knowledge base has realized the transformation of the responsibility system and evidence-based nursing model with patient-centered and nursing procedures as the core, improving nursing quality and efficiency, and ensuring patient safety.

关 键 词：临床决策支持 智慧护理 知识库 任务导向 数据一元化 

分 类 号：R319[医药卫生—基础医学]