基于临床护理分类系统的电子病历设计与实现  

Design and Implementation of Electronic Medical Record Based on Clinical Nursing Classification System

作　　者：史超[1] 林栋羚[1] 陈桂花[1] 魏晓艳[1] Shi Chao;Lin Dongling;Chen Guihua;Wei Xiaoyan(The First Affiliated Hospital of Xinjiang Medical University,Urumqi 830054,Xinjiang Uygur Autonomous Region,China;不详)

机构地区：[1]新疆医科大学第一附属医院,新疆维吾尔自治区乌鲁木齐市830054

出　　处：《中国病案》2023年第8期3-7,共5页Chinese Medical Record

基　　金：新疆护理学会课题项目(2018XH50)。

摘　　要：针对电子病历系统术语规范性差、映射能力不足、兼容性低等问题进行分析,结合临床护理分类系统护理术语的权威性、信息整合能力突出、信息共享程度高、数据加工能力强的优势,在分析了临床护理分类系统结构的基础上,运用护理诊断编码分类技术建立数据库,设计了基于临床护理分类的电子病历系统。系统具有结构层次分明、术语分类管理、组配灵活、流程科学的特点。通过独特的编码体系,识别并整合护理文书中的独立信息元素,为使用者提供了科学、规范的护理语言;丰富了医院信息系统数据接口,提升了信息共享性;提高了护理文书质量、填写效率与信息获得途径;降低了填写问题缺陷。Based on the analysis of the problems of poor standardization,inadequate mapping ability and low compatibility of electronic medical record system terms,combined with the advantages of clinical nursing classification system nursing terms authority,outstanding information integration ability,high information sharing degree and strong data processing ability,based on the analysis of clinical nursing classification system structure,the use of nursing diagnosis coding classification technology to establish a database.An electronic medical record system based on clinical nursing classification is designed.Through the unique coding system,the independent information elements in nursing documents are identified and integrated to provide users with scientific and standardized nursing language.It enriches the data interface of hospital information system and enhances the sharing of information.Improve the quality of nursing documents,filling efficiency and access to information;Reduce the problem filling defects.The system is characterized by distinct structure,classified management of terms,flexible assembly and scientific flow.

关 键 词：护理分类系统 电子病历 设计与实现 

分 类 号：R197.323[医药卫生—卫生事业管理]