基于任务导向的护理信息系统改造  

Task-oriented nursing information system upgrading

作　　者：乔梦薇 熊伟昕[1] 王毅[1] 余俊蓉[1] 黎鹏安 QIAO Mengwei;XIONG Weixin;WANG Yi;YU Junrong;LI Peng’an(The First Affiliated Hospital,Sun Yat-sen University,Guangzhou 510080,China)

机构地区：[1]中山大学附属第一医院,广东广州510080

出　　处：《现代医院》2024年第8期1274-1277,1280,共5页Modern Hospitals

摘　　要：目的结合智慧医院建设背景,搭建稳定、高效的护理信息系统。方法基于医院数据集成平台,优化数据采集策略,围绕患者“入转出”,分析各环节护理任务,创建时间轴任务管理清单,在重要护理环节引入智能辅助提醒和决策功能,比较系统升级前后文书结构化率、每日文书录入耗时、巡视及时率、给药时间符合率以及护理满意度,评价系统改造效果。结果实现护理文书高度结构化和可配置化,每日文书录入耗时降低了约1.16 h,巡视及时率和给药时间符合率明显提高,护理满意度较高。结论基于任务导向的护理工作模式,提高了护理效率与安全,推动护理模式转变。Objective This study aims to establish a stable and efficient nursing information system in the context of smart hospital development.Methods Leveraging the hospital's health information exchange(HIE)platform,we optimized data collection strategies.Focusing on“patient’s admission,transfer,and discharge”,we analyzed nursing tasks at each link and created a comprehensive management task list based on the timeline.Key nursing steps incorporated intelligent assistive reminders and decision-making functions.The upgraded system was evaluated by comparing pre-and post-upgrade metrics:structured rates of documentation,daily time spent on the document entry,timeliness of rounds,rate of timely medication administration,and nursing satisfaction.Results The nursing documentation became highly structured and configurable,with daily documentation time reduced by approximately 1.16 hours.There were significant improvements in the timeliness of rounds and the rate of timely medication administration,alongside high nursing satisfaction.Conclusion The task-oriented nursing pattern can enhance nursing efficiency and safety,facilitating a shift in the nursing model.

关 键 词：智慧医院 护理文书 移动护理 任务导向 辅助决策 

分 类 号：R47-05[医药卫生—护理学] R319[医药卫生—临床医学]