新一代临床护理信息系统建设与应用实践

摘要

Objectives: To develop a new generation of clinical nursing information system to match the requirement of medical health big data, mobile internet and refine management of nursing and to overcome the shortages that the nurse workstation plays inadequate role on supporting professional nursing service. Methods: The nursing information needs were analyzed. The information system function model in aspects of nursing document quality control, mobile nursing and performance management was established to assure information technology support and application. Result: A new generation of clinical nursing information system software was developed and applied in more than 40 departments in our hospital and the nursing related informatization was shaped. Conclusions: Nursing informatization is an important part of hospital information construction and needs to overall planning and construction to ensure patient safety.%目的：研发新一代临床护理信息系统，满足医疗健康大数据、移动互联与护理精细化管理要求，克服护士工作站对护理专业本身支持不足的缺点。方法：分析护理工作信息需求，从护理文档、护理质控、移动护理以及绩效管理等方面建立信息系统功能模型，实现电子化信息化支撑，并在应用中改进。结果：建立了新一代临床护理信息系统软件，在医院40多个病区进行了应用，形成了比较完整的临床护理信息化解决方案。结论：护理信息化是医院临床信息建设的重要部分，需要整体规划建设，以保障病人医疗安全。