基于HIS的护理文书质控系统的设计与应用  

Design and application of a HIS-based quality control system for nursing documents

作　　者：周红[1] 王巍[1] 郑蓉[2] Zhou Hong;Wang Wei;Zheng Rong(Information Department,Wuhan No.1 Hospital,Wuhan 430000,Hubei Province,China;Cardiovascular Medicine Department,Wuhan No.1 Hospital,Wuhan 430000,Hubei Province,China)

机构地区：[1]武汉市第一医院信息中心,武汉430000 [2]武汉市第一医院心血管内科,武汉430000

出　　处：《中国数字医学》2022年第12期40-44,共5页China Digital Medicine

摘　　要：目的:设计基于HIS的护理文书质控系统,旨在提高护理文书的质量。方法:组建项目小组,结合护理文书书写规范和临床需求,设计开发基于HIS的护理文书质控系统,并应用于临床。结果:基于HIS的护理文书质控系统投入使用后,缩短了护理人员每日护理文书质控时长,减少了护理文书修改的次数,降低了护理文书质控扣分,提高了护理文书的质量。结论:基于HIS的护理文书质控系统促进了护理文书的规范化管理,有效提高了护理人员的工作效率,提高了终末护理文书的质量。Objective To design a HIS-based quality control system for nursing documents,aiming at improving its quality.Methods Based on nursing documents writing specifications and clinical needs,a project team was formed to design and develop a HIS-based quality control system for nursing documents,which was applied to clinical practice.Results After the HIS-based quality control system for nursing documents was put into use,it shortened the daily nursing documents quality control time of nursing staff,reduced the number of nursing document revisions and the deduction points of nursing documents quality control,and improved the nursing documents quality.Conclusion The HIS-based quality control system for nursing documents system can facilitate the standardized management of nursing documents,and effectively improve the work efficiency of nursing staff and the quality of end-of-life nursing documents.

关 键 词：护理文书 护理信息化 质控 HIS 护理白板 

分 类 号：R319[医药卫生—基础医学] TP391[自动化与计算机技术—计算机应用技术]