重症护理文书智能化闭环质控系统设计与应用  

Design and Application of Intelligent Closed-Loop Quality Control System for Critical Care Nursing Documents

作　　者：王丹丹 贺文静 周华[1] 郭秀辰 赵文静 WANG Dandan;HE Wenjing;ZHOU Hua(Beijing Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua University,Beijing,102218,China;不详)

机构地区：[1]清华大学附属北京清华长庚医院,北京102218

出　　处：《中国卫生质量管理》2024年第7期22-26,共5页Chinese Health Quality Management

基　　金：国家重点研发计划(编号:12022A2009);清华大学智慧医疗项目(编号:12022B7043)。

摘　　要：借助信息技术对重症护理文书进行过程质控是护理管理重点。从临床护士视角出发,梳理重症护理文书开始生成到归档全流程,结合重症专科护理文书质控需求,基于关键点控制理论,设置患者入科、护理风险评估、护理处置、护理交接班、出科质控5个关键功能模块,并构建子模块,形成了重症护理文书智能化闭环质控系统,实现了对重症护理文书的“事前预防、事中监管、事后反馈”闭环管理,提高了护理文书书写效率,提升了护理文书书写质量。Process quality control of critical care nursing documents with the help of information technology is the focus of nursing management.From the perspective of clinical nurses,the whole process of critical care documents was sorted out,combined with the quality control needs of critical care documents and based on the key point control theory,five key functional modules were set up,including patient admission,nursing risk assessment,nursing disposal,nursing shift transfer and discharge quality control,and sub-modules were constructed to form an intelligent closed-loop quality control system for critical care documents.The closed-loop management of"prevention before the event,supervision during the event and feedback after the event"of critical nursing documents had been realized,which had improved the efficiency and quality of nursing documents writing.

关 键 词：重症医学科 护理文书 复合闭环管理 智能化 护理质控 

分 类 号：R47[医药卫生—护理学]