CN103455961A - Patient high risk factor nursing assessment system - Google Patents
Patient high risk factor nursing assessment system Download PDFInfo
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- CN103455961A CN103455961A CN2013104092991A CN201310409299A CN103455961A CN 103455961 A CN103455961 A CN 103455961A CN 2013104092991 A CN2013104092991 A CN 2013104092991A CN 201310409299 A CN201310409299 A CN 201310409299A CN 103455961 A CN103455961 A CN 103455961A
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Abstract
The invention relates to the field of medical nursing, in particular to a patient high risk factor nursing assessment system. The patient high risk factor nursing assessment system comprises a nursing knowledge base, and the nursing knowledge base comprises a nursing assessment module and a nursing measure module. Patient high risk factor nursing assessment standards are stored in the nursing assessment module, and nursing measure data are stored in the nursing measure module. Corresponding high risk factors of a patient are selected, are compared with the patient high risk factor nursing assessment standards and are quantized to acquire specific numerical values, and corresponding nursing measures are searched in the nursing measure module according to the numerical values. Due to the application of the patient high risk factor nursing assessment system, corresponding nursing measures can be selected from the nursing measure module by nurses according to personal conditions of the patient and the patient high risk factor nursing assessment system.
Description
Technical field
The present invention relates to medical care, more particularly, relate to a kind of patient's high risk factor nursing evaluating system.
Background technology
Carry out high quality nursing work, one of important connotation of implementing " responsibility system holistic Nursing " pattern is to improve the ability of clinical nurse nursing program.The nursing assessment is the first step of care program, a very crucial step.The clinical care assessment is mainly obtained by main suit, observation and medical history information, with form row papery NN.Because the clinical care evaluation criteria is uneven, there is not yet the systematization standard, papery nursing assessment increases the nursing time, easily occurs to leak to comment phenomenon.The nurse lacks effective assessment mode on patient's change of illness state at present, often causes nurse's prevention work to be implemented not in place.
Summary of the invention
The object of the invention is to overcome the deficiencies in the prior art, provide a kind of nurse according to patient's individual instances, according to patient's high risk factor nursing evaluating system, to select patient's high risk factor nursing evaluating system of corresponding nursing intervention in the nursing intervention module.
Technical scheme of the present invention is as follows:
A kind of patient's high risk factor nursing evaluating system, comprise nursing knowledge base, and nursing knowledge base comprises nursing evaluation module, nursing intervention module; Storage patient high risk factor nursing evaluation criteria in the nursing evaluation module, storage nursing intervention data in the nursing intervention module; Choose the corresponding high risk factor of patient, and contrasted with patient's high risk factor nursing evaluation criteria, and quantize to obtain concrete numerical value, search corresponding nursing intervention according to numerical value in the nursing intervention module.
As preferably, login patient's high risk factor nursing evaluating system by wireless handheld terminal, and choose the corresponding high risk factor of patient and patient's high risk factor nursing evaluation criteria and contrasted, and quantize to obtain concrete numerical value, search corresponding nursing intervention in the nursing intervention module according to numerical value.
As preferably, electronic medical record system is set, patient's disease information is kept in electronic medical record system, and electronic medical record system is associated with nursing knowledge base, form the nursing assessed value, the nursing intervention that are associated with patient.
As preferably, patient's high risk factor nursing evaluation criteria comprises risk factors of pressure sore for patients evaluation module, hazards unscheduled event evaluation module.
As preferably, the risk factors of pressure sore for patients evaluation module comprises WaterIow pressure sore risk assessment submodule, Braden pressure sore risk assessment submodule, Worton pressure sore risk assessment submodule.
As preferably, also store sickness nursing information in the nursing evaluation module, sickness nursing information comprises disease category, significant notation, operation mark.
As preferably, patient's high risk factor nursing assessment is internuncial in time, and after certain time interval, copying and saving nursing assessment, nursing intervention, reach the purpose that repeatedly nursing is carried out.
As preferably, the nurse uses wireless handheld terminal typing patient's high risk factor, is kept in the database of electronic medical record system, and electronic health record can be retrieved view and quote assessment result on the NN interface.
As preferably, in electronic medical record system, the step of typing patient's high risk factor is as follows: the information of handheld terminal typing, be assembled into the content of specific XML form by the Intranet service end, the Chronic Disease in Community care management system receives the content of specific XML form, and the translation data form, carry out information updating.
Beneficial effect of the present invention is as follows:
System of the present invention is set up patient's high risk factor nursing appraisal procedure under wireless handheld terminal (PDA) is supported, a plurality of high risk factor nursing evaluation modules are set, set up the evaluation form of patient's high risk factor, can make nurse's reference standard in time the high risk patient be assessed, improve nurse's specific nursing evaluation capacity, take preventive measures, avoid bad nursing accident event to occur, improve nursing quality, ensure patient safety.The nurse can choose nursing intervention targetedly according to patient's individual instances, makes the paramedic accomplish to know what's what, emphasis is arranged in work, reduce work blindly, effectively prevent conditions of patients to worsen the probability occurred, make nursing intervention move towards institutionalization, sequencing, hommization and scientific.Therefore it is single that design is used in the nursing assessment of inpatient, strengthen the systematization assessment to the patient care risk, choose nursing targetedly according to patient's nursing assessment situation, save the nursing time, promote patient's nursing safety and nursing quality.
System of the present invention, set up the evaluation form of patient's high risk factor, can make nurse's reference standard in time the high risk patient be assessed, improve nurse's specific nursing evaluation capacity, take preventive measures, avoid unscheduled event to occur, improve nursing quality, ensure patient safety, there is social benefit preferably, have a extensive future.
Normalized nursing estimation flow and content, have important evidence for the nursing evaluation system of Criterion, and social benefit is better.
Wireless handheld terminal is directly realized assessment whenever and wherever possible, and the assessment content is directly held and generated electronic care record by PC, reduces the electronic structure NN time, really will the time return the patient, realizes patient satisfaction, nurse's satisfaction, has good social benefit.
The accompanying drawing explanation
Fig. 1 is the enforcement schematic diagram of high risk factor nursing evaluation item;
Fig. 2 repeats care regimen and the enforcement schematic diagram one of nursing assessment every day;
Fig. 3 repeats care regimen and the enforcement schematic diagram two of nursing assessment every day;
Fig. 4 repeats care regimen and the enforcement schematic diagram three of nursing assessment every day;
Fig. 5 is high risk factor nursing evaluation module and the data sharing of electronic medical record system and the enforcement schematic diagram of synchronizeing;
Fig. 6 is the data structure schematic diagram of the background service database of electronic medical record system.
Embodiment
Below in conjunction with drawings and Examples, the present invention is described in further detail.
A kind of patient's high risk factor nursing evaluating system, comprise nursing knowledge base, and nursing knowledge base comprises nursing evaluation module, nursing intervention module; Storage patient high risk factor nursing evaluation criteria in the nursing evaluation module, storage nursing intervention data in the nursing intervention module; Choose the corresponding high risk factor of patient, and contrasted with patient's high risk factor nursing evaluation criteria, and quantize to obtain concrete numerical value, search corresponding nursing intervention according to numerical value in the nursing intervention module.
Login patient's high risk factor nursing evaluating system by wireless handheld terminal, and choose the corresponding high risk factor of patient and patient's high risk factor nursing evaluation criteria and contrasted, and quantize to obtain concrete numerical value, search corresponding nursing intervention in the nursing intervention module according to numerical value.
Electronic medical record system is set, patient's disease information is kept in electronic medical record system, and electronic medical record system is associated with nursing knowledge base, form the nursing assessed value, the nursing intervention that are associated with patient.
The nurse uses wireless handheld terminal typing patient's high risk factor, is kept in the database of electronic medical record system, and electronic health record can be retrieved view and quote assessment result on the NN interface.
In electronic medical record system, the step of typing patient's high risk factor is as follows: the information of handheld terminal typing, be assembled into the content of specific XML form by the Intranet service end, the Chronic Disease in Community care management system receives the content of specific XML form, and the translation data form, carries out information updating.
Patient's high risk factor nursing evaluation criteria comprises risk factors of pressure sore for patients evaluation module, hazards unscheduled event evaluation module.The risk factors of pressure sore for patients evaluation module comprises WaterIow pressure sore risk assessment submodule, Braden pressure sore risk assessment submodule, Worton pressure sore risk assessment submodule.
Also store sickness nursing information in the nursing evaluation module, sickness nursing information comprises disease category, significant notation, operation mark.
Patient's high risk factor nursing assessment is internuncial in time, and after certain time interval, copying and saving nursing assessment, nursing intervention, reach the purpose that repeatedly nursing is carried out.
Embodiment
The present embodiment be take hypertension as example, carries out the implementation of system.
Set up nursing knowledge base, by the caregiver, common high risk factor nursing assessment is carried out to classified finishing, multinomial nursing evaluation module and corresponding nursing intervention module are set, " the nursing assessment path " system of holding by PC is unified maintenance management, solves the problem of nursing knowledge management maintenance difficulty.
Wireless handheld terminal (PDA) is by the wireless network of hospital; connect nursing knowledge base; utilize the portability of PDA; retrieve the nursing appreciation information of relevant disease whenever and wherever possible and show; the nursing prompting that the nurse gives by checking PDA; according to set nursing flow process; the enterprising line correlation operation at the PDA interface; guarantee to nurse accuracy, the standardization of flow process, nursing assessment; as change; need to fill in statement on changes, the executive logging of nursing assessment with digitized form permanent storage to the background service database.Solve the weak link of nursing assessment, reduce the NN time, realize the side assessment, and automatically generate record.
Portable wireless terminal and computer terminal port link, and automatically on electronic medical record system, generate NN.
As shown in Figure 6, electronic medical record system (HIS) comprises for storing the background service database of disease that calls for specialized treatment nursing content and various nursing evaluation modules.Wherein, the disease that calls for specialized treatment nursing content includes disease that calls for specialized treatment classification dictionary, schedule dictionary, disease that calls for specialized treatment noun dictionary etc.Various nursing assessment lists comprise that assessment used record sheet, disease that calls for specialized treatment NN master meter, disease that calls for specialized treatment nursing to use and record master meter etc.Assessment is used record sheet to comprise assessment list, evaluation item list, assessment name dictionary, evaluation item etc., and assessment is used record sheet can be converted into the assessment result view.Information in above-mentioned background service database can be called as required or upgrade.
Increase the nursing evaluation profile of continuity high risk factor, the nurse can carry out the assessment of patient's high risk factor with PDA, take PDA as support, import tabular special care evaluation item, be risk factors of pressure sore for patients assessment (WaterIow pressure sore risk assessment, Braden pressure sore risk assessment, Worton pressure sore risk assessment etc.), hazards unscheduled event assessment (falling, fall bed etc.), automatically quantize mark after each project evaluation, divided rank is set and reminds.
By portable wireless handheld terminal (PDA), obtain the disease that calls for specialized treatment nursing assessment of having safeguarded, anywhere or anytime in the optional position, lesion, according to the PDA information, instruct the nurse, patient is carried out to standard, specialty, comprehensively nursing assessment and processing, reduce nursing cost, and the content after assessment is linked by PDA and computer terminal, being saved in the electronic structure nursing history, persistence is to system.
Tabular special evaluation item is imported to pda system, comprise risk factors of pressure sore for patients assessment, hazards unscheduled event assessment (falling, fall bed etc.) etc., the other assessment of the with no paper bed of row, automatically quantize mark after assessment, and prompting evaluation grade, can directly proceed to corresponding treatment measures, save the nursing time, new nurse is had to the positive orientation guide function.
During concrete enforcement, each major part is as follows.
One, nursing knowledge base
1, sickness nursing information comprises: disease category, significant notation, operation mark.
2, high risk factor nursing evaluation item, as shown in Figure 1, the high risk factor assessment comprises risk factors of pressure sore for patients assessment (WaterIow pressure sore risk assessment, Braden pressure sore risk assessment, Worton pressure sore risk assessment etc.), hazards unscheduled event assessment (falling, fall bed etc.).
Entry setting and score are carried out in evaluation item externally applied forces, expectation operating time, 7 aspects of particular procedure factor from patient with operation age, constitutional index, stress point skin conditions, operation position, expectation art, be divided into 3 grades according to the cumulative total points obtained of each entry, and implement according to this classfied system of nursing intervention, the people at highest risk of pressure sore effectively occurs in predicting surgical, improves the specific aim of nursing intervention measures.
Two, PDA terminal high risk factor assessment nursing
(1) nursing assessment
1, template is carried out in the nursing assessment of safeguarding backstage, can carry out orderly nursing assessment by instructing with the standard nurse to patient in the PDA terminal.The PDA terminal is carried out particular design to the high risk factor evaluation item; Special evaluation item can associated concrete score value, as after bedsore evaluation, each project evaluation of assessment of falling, automatically quantized mark, divided rank is set and reminds.
2, the nursing safety evaluation module arranges
List risk factors of pressure sore for patients assessment, hazards unscheduled event assessment (comprise and fall, fall bed etc.) project in the nursing evaluation module, content comprises patient's essential information, evaluation item content and score value, total points and practical step implementation of conditions option (totally 15) is arranged, and evaluation form again finally is set.After the nurse carries out the special care assessment, the automatic compute associations score value of PDA.
(2) repeat care regimen and nursing assessment every day
The nurse, according to patient's situation, is copied care regimen, nursing assessment, and is shown with " [date] [project name] " format, as shown in Figure 2, Figure 3, Figure 4; And record respectively operating result, reach the purpose that special disease is repeatedly nursed execution.
(3) data sharing with synchronize
Realize relevant interface by the application system from different, but the real data sharing and synchronization.The nursing assessment data shares to the Hospital Electronic Medical Record system, completes the typing of NN list, as shown in Figure 5.
Above-described embodiment is only for the present invention is described, and not as limitation of the invention.So long as according to technical spirit of the present invention, to above-described embodiment changed, modification etc. all will drop in the scope of claim of the present invention.
Claims (9)
1. patient's high risk factor nursing evaluating system, is characterized in that, comprise nursing knowledge base, nursing knowledge base comprises nursing evaluation module, nursing intervention module; Storage patient high risk factor nursing evaluation criteria in the nursing evaluation module, storage nursing intervention data in the nursing intervention module; Choose the corresponding high risk factor of patient, and contrasted with patient's high risk factor nursing evaluation criteria, automatically quantize to obtain concrete numerical value, search corresponding nursing intervention according to numerical value in the nursing intervention module.
2. patient's high risk factor according to claim 1 is nursed evaluating system, it is characterized in that, login patient's high risk factor nursing evaluating system by wireless handheld terminal, and typing patient's high risk factor and patient's high risk factor nursing evaluation criteria is contrasted, and quantize to obtain concrete numerical value, search corresponding nursing intervention in the nursing intervention module according to numerical value.
3. patient's high risk factor according to claim 2 is nursed evaluating system, it is characterized in that, electronic medical record system is set, patient's disease information is kept in electronic medical record system, and electronic medical record system is associated with nursing knowledge base, form the nursing assessed value, the nursing intervention that are associated with patient.
4. patient's high risk factor nursing evaluating system according to claim 1, is characterized in that, patient's high risk factor nursing evaluation criteria comprises risk factors of pressure sore for patients evaluation module, hazards unscheduled event evaluation module.
5. patient's high risk factor according to claim 1 is nursed evaluating system, it is characterized in that, the risk factors of pressure sore for patients evaluation module comprises WaterIow pressure sore risk assessment submodule, Braden pressure sore risk assessment submodule, Worton pressure sore risk assessment submodule.
6. patient's high risk factor nursing evaluating system according to claim 1, is characterized in that, also store sickness nursing information in the nursing evaluation module, sickness nursing information comprises disease category, significant notation, operation mark.
7. patient's high risk factor according to claim 1 is nursed evaluating system, it is characterized in that, patient's high risk factor nursing assessment is internuncial in time, after certain time interval, copying and saving nursing assessment, nursing intervention, reach the purpose that repeatedly nursing is carried out.
8. patient's high risk factor according to claim 3 is nursed evaluating system, it is characterized in that, the nurse uses wireless handheld terminal typing patient's high risk factor, is kept in the database of electronic medical record system, and electronic health record can be retrieved view and quote assessment result on the NN interface.
9. patient's high risk factor according to claim 8 is nursed evaluating system, it is characterized in that, in electronic medical record system, the step of typing patient's high risk factor is as follows: the information of handheld terminal typing, be assembled into the content of specific XML form by the Intranet service end, the Chronic Disease in Community care management system receives the content of specific XML form, and the translation data form, carry out information updating.
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| CN113948204A (en) * | 2021-10-22 | 2022-01-18 | 南方医科大学珠江医院 | Ending-oriented whole-course model nursing data processing method |
| CN113948204B (en) * | 2021-10-22 | 2022-04-22 | 南方医科大学珠江医院 | Ending-oriented whole-course model nursing data processing method |
| CN115274089A (en) * | 2022-06-06 | 2022-11-01 | 安徽省立医院(中国科学技术大学附属第一医院) | Nursing risk assessment early warning method and system |
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