[1]刘宏见,牟绍玉,罗静,等.基于临床护理分类系统的重症监护室电子护理记录系统的开发与应用[J].军事护理,2021,38(08):85-88.[doi:10.3969/j.issn.1008-9993.2021.08.023]
　LIU Hongjian,MOU Shaoyu,LUO Jing,et al.Development and Application of Electronic Nursing Recording System of Intensive Care Units Based on the Clinical Care Classification System[J].Nursing Journal Of Chinese People's Laberation Army,2021,38(08):85-88.[doi:10.3969/j.issn.1008-9993.2021.08.023]
点击复制

基于临床护理分类系统的重症监护室电子护理记录系统的开发与应用
分享到：

《军事护理》[ISSN:2097-1826/CN:31-3186/R]

卷:
38
期数:
2021年08期
页码:
85-88
栏目:
护理管理
出版日期:
2021-08-15

文章信息/Info

Title:
Development and Application of Electronic Nursing Recording System of Intensive Care Units Based on the Clinical Care Classification System
文章编号:
1008-9993(2021)08-0085-04
作者:
刘宏见1; 牟绍玉2; 罗静1; 冉琴1; 黄子权1
(1.重庆医科大学附属大学城医院 重症医学科,重庆 401331; 2.重庆医科大学 护理学院,重庆 400016)
Author(s):
LIU Hongjian1; MOU Shaoyu2; LUO Jing1; RAN Qin1; HUANG Ziquan1
(1.Intensive Care Unit,University-Town Hospital of Chongqing Medical University,Chongqing 401331,China; 2.School of Nursing,Chongqing Medical University,Chongqing 400016,China)
关键词:
临床护理分类系统;  标准化护理术语;  电子护理记录;  重症监护病房
Keywords:
clinical care classification system;  standardized nursing terminologies;  electronic nursing records;  intensive care unit
分类号:
R47
DOI:
10.3969/j.issn.1008-9993.2021.08.023
文献标志码:
A
摘要:
目的 基于临床护理分类系统(clinical care classification,CCC)设计开发结构化电子护理记录系统,并评价其应用价值,为促进护理标准化术语建设提供实证参考。方法 基于CCC的框架结构和术语体系,设计开发结构化的电子护理记录系统,并应用于重症监护室(intensive care unit,ICU)的临床护理实践。通过分析CCC术语的使用频率、分布特点、护理记录时间等指标,评价其应用效果。结果 共使用CCC术语24 990条,其中护理诊断5052条、护理措施7443条; 176项护理诊断术语中实际使用93项(52.80%)、201项护理措施术语中实际使用108项(53.73%); 护士找到所需术语的成功率为89.43%。每次文档录入的平均时间从170.5 s缩短到95.5 s。结论 基于CCC的电子护理记录系统能反映ICU护理工作特点及患者病情特点,提高护理记录效率,实现了临床护理信息的标准化表达和数据共享。
Abstract:
Objective To design and develop a structured electronic nursing recording system based on the Clinical Care Classification(CCC)System,and evaluate its application value,so as to provide empirical references for promoting the construction of standardized nursing terminologies.Methods A structured electronic nursing recording system was designed and developed based on the structure and terminology of CCC,and then applied in the clinical nursing practice of intensive care units(ICU).The indicators of usage frequency and distribution characteristics of CCC terminology,as well as recording time were analyzed to evaluate its application value.Results A total of 24,990 CCC terms were used,including 5052 terms of nursing diagnoses and 7443 terms of nursing interventions.Among the 176 terms of nursing diagnoses,93(52.80%)terms were actually used; 108(53.73%)terms were actually used among the 201 terms of nursing interventions.The success rate of identifying the required terms was 89.43%.The average time of each record inputting was reduced from 170.5 seconds to 95.5 seconds.Conclusions The electronic nursing recording system based on CCC can reflect the characteristics of ICU nursing work and patients' conditions,improve the efficiency of nursing recording,and achieve the standardized expression of clinical nursing information and data sharing.

参考文献/References:

[1] 刘晓玲,张宁.护理信息化建设对内分泌患者优质护理工作的影响[J].中国数字医学,2020,15(9):145-147.
[2] 孙霁雯,楼建华,沈南平,护理记录结构化标准化的反思[J],解放军护理杂志,2015,32(23):35-37.
[3] 卞丽芳,李琰,谢薇,等.英国医院胰十二指肠切除术后快速康复路径表的设计特点及启示[J].中华护理杂志,2016,51(12):1525-1528.
[4] LEE J Y,PARK H A.Development and validation of detailed clinical models for nursing actions in perinatal care[J].Int J Med Inform,2017(102):103-110.
[5] 刘宏见,牟绍玉,罗静,等.临床护理分类系统在重症监护病房护理记录中的适用性研究[J].护理研究,2020,34(24):4436-4440.
[6] 林敏,陈京立,康晓凤,等.临床护理分类系统在电子病历中的研究及应用进展[J].中国护理管理,2019,19(5):735-739.
[7] 秦丽丽,严婷,徐宇红,等.基于医院信息系统的结构化护理不良事件管理系统的研发及应用[J].解放军护理杂志,2020,37(8):83-86.
[8] Clinical Care Classification System.Framework[EB/OL].[2021-03-21].https://careclassification.org/framework/.
[9] MOSS J A,DAMRONGSAK M,GALLICHIO K.Representing critical care data using the clinical care classification[J/OL]. [2021-04-11].https://pubmed.ncbi.nlm.nih.gov/16779099/.
[10]纪小波,曹串,杨磊,等.临床照护分类系统在综合ICU护理实践中的应用分析与展望[J].中华护理杂志,2020,55(03):391-396.
[11]FENG R C,TSENG K J,YAN H F,et al.Capability of using clinical care classification system to represent nursing practice in acute setting in Taiwan[J/OL].[2021-04-11]./https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799145/.
[12]韩海燕,高秀秀,杨磊,等.临床照护分类系统在骨科护理实践中的应用[J].中国护理管理,2020,20(6):911-916.
[13]梁爱华,张俊波,刘桂平,等.结构式专科护理记录单模板的设计与应用[J].齐鲁护理杂志,2016,22(6):120-122.
(本文编辑:王园园)

备注/Memo

备注/Memo:
【 收稿日期 】 2021-04-30 【 修回日期 】 2021-07-05
【 基金项目 】 重庆市2019年科卫联合医学科研项目(2019MSXM020); 重庆医科大学智慧医学项目(ZHYX2019021)
【 作者简介 】 刘宏见,硕士在读,副主任护师,从事护理信息学、危重症护理研究
【 通信作者 】 牟绍玉,电话:023-63555763
更新日期/Last Update: 2021-08-15