CN104408329A - Electronic clinical nursing path management system and method - Google Patents
Electronic clinical nursing path management system and method Download PDFInfo
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- CN104408329A CN104408329A CN201410795013.2A CN201410795013A CN104408329A CN 104408329 A CN104408329 A CN 104408329A CN 201410795013 A CN201410795013 A CN 201410795013A CN 104408329 A CN104408329 A CN 104408329A
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Abstract
The invention relates to an electronic clinical nursing path management system. The electronic clinical nursing path management system comprises a server, a management terminal and a medical care terminal, wherein the server is provided with a database, and patient diagnosis information, medical record information and clinical nursing path templates established based on diagnosis are stored in the database; the medical care terminal is used for acquiring the patient diagnosis information from the database of the server, selecting a matched clinical nursing path template from the database according to the patient diagnosis information to establish an actual clinical nursing path, automatically recording the execution condition, the nursing condition and a result of the actual clinical nursing path, synchronously completing corresponding nursing record and uploading the execution condition the nursing condition, the result and a nursing record form to the server; the management terminal is used for inputting the clinical nursing path template and monitoring and managing the actual clinical nursing path according to the execution condition, the nursing condition and the result. According to the electronic clinical nursing path management system, unified and standardized management for the clinical nursing path is realized, the accurate path execution can be guaranteed, the medical nursing quality is improved and the like.
Description
Technical field
The present invention relates to medical information administrative skill field, particularly the electronic clinical nursing path management system of one and method.
Background technology
Clinical nursing path (Clinical Pathway CP) refers to by " medical treatment, nursing and the personnel of relevant speciality " after medical diagnosis on disease is clear and definite, that formulates for " certain diagnosis or certain operation " has scientific and time sequencing " patient looks after plan ", on existing diagnosis and treatment process base, with reference to the achievement in research of evidence-based medicine EBM, Industrial Engineering and quality management subject, to crucial diagnosis and treatment activity, measure and time normalization regulation, and provide service to patient based on this.Clinical nursing path (Clinical Nursing Pathway, CNP) is clinical nursing path is the application of clinical path in nursing.
The core of clinical path management: 1, standardized work: by activity standard such as certain disease (operation) critical inspection, treatment, nursing; guarantee that patient is in the correct time; correct place, obtains correct consulting services, to reaching optimum therapeuticing effect.2, flow process is integrated: remove, simplify, merge and robotization principle, original diagnosis and treatment flow process is integrated, reduces valueless content, raise the efficiency, reduce mistake.3, team collaboration: cure, protect, medicine, skill, the role of patient, the division of labor clear in job responsibility, jointly tackle.
At present, most domestic hospital adopt the Ministry of Public Health within 2009, write clinical nursing path list, content is medical care general-purpose version, nursery work content by doctor assist safeguard, content is extensive, does not have specific aim.Complete list and record hand-written completing and electronization execution 2 kinds of modes.The hand-written list completed: list content is made Word document, prints, doctor and nursing are chosen respectively in corresponding form, and will write certain content.Intensive and the statistical function of electronization cannot be completed.Written contents is random, cannot standardization, can not meet the standardisation requirements of clinical nursing path.Electronization clinical nursing path be usually integrated in his system, manner of execution is generally and clicks path content data, confirm " execution ".There is following problem in the method: 1, " execution " in path and the actual of patient benefit to disconnect, although patient has received corresponding medical treatment and nursing service, list has often occurred postponing " execution ", has leaked " execution ", has not had " execution " situation even completely.2, path management nursing behavior cannot be used.3, the effect after path " execution " cannot embody, and synchronously cannot complete NN.4, path design intension is not enough, and cause variation incidence high, mutagen is because selecting arbitrarily.
Summary of the invention
Fundamental purpose of the present invention is, for above-mentioned deficiency of the prior art, provides a kind of electronic clinical nursing path management system and method.
The present invention solves the technical scheme that prior art problem adopts: a kind of electronic clinical nursing path management system, comprising:
Server, described server has a database, described database purchase have patient's diagnostic message, medical record information, with based on diagnosing the clinical nursing path template set up; Described clinical nursing path template comprises timing node and the nursing content corresponding with each timing node.
Medical care terminal, described medical care terminal is connected by described communication network with described server, for obtaining diagnosing patient information in the database from described server, from described database, adaptive clinical nursing path template is selected to set up the actual clinical nursing path of this patient according to described diagnosing patient information, and automatically record the implementation status of described actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database of described server;
Office terminal, described office terminal is connected by communication network with described server, for clinical nursing path template described in typing, and described clinical nursing path template be uploaded in the database of described server, and according to described implementation status, nursing situation and result, monitoring management is carried out to described actual clinical nursing path.
Preferably, described medical care terminal comprises:
Data obtaining module, for obtaining the diagnosing patient information of patient from described server;
Module is set up in path, for according to described diagnosing patient information, the clinical nursing path template suitable with described diagnosing patient information is matched from the database of described server, and set up the actual clinical nursing path of this patient according to this clinical nursing path template, and described actual clinical nursing path is stored in the database of described server;
NN module, for automatically recording the implementation status, nursing situation and the result that perform described actual clinical nursing path, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database of described server;
Preferably, described medical care terminal also comprises:
Quality inspection control module, for the implementation status of actual clinical nursing path described in monitor and detection, when detecting that the essential nursing content of the upper timing node in described actual clinical nursing path does not perform, control the future time node that described NN module can not enter actual clinical nursing path.
Preferably, described office terminal comprises:
Typing module, for typing clinical nursing path template, and is uploaded in the database of described server;
Path management module, for obtaining described implementation status, nursing situation and result, and according to described implementation status, nursing situation and result to the actual clinical nursing path monitoring management of patient from server.
Preferably, described path management module comprises:
Statistical module, for obtaining described nursing situation and result from server, and by described nursing situation and result and situation is nursed in expection and result contrasts, judges whether described nursing situation and result morph;
Revision module, for when described nursing situation and result morph, modifies to the actual clinical nursing path of described patient.
Preferably, described office terminal also comprises:
List generation module, for generating the NN list of the execution list of actual clinical nursing path, nursing situation and result.
Preferably, described office terminal also comprises:
List binding module, for predetermined time node is needed write specific Nursing recording list single class and described predetermined time node in addition " binding ", during to make this timing node of execution, automatically can enter into the NN list of predetermined type;
And need default timing node to write the observation item of specific NN content and described default timing node in addition " binding ", to make when performing this timing node, automatically enter into the observation item preset, record is carried out to it, with the NN of generating standard.
Preferably, described office terminal also comprises:
Authority management module, for managing the authority of the actual clinical nursing path of patient being carried out to the user of management maintenance.
Preferably, the clinical nursing path template that same case is corresponding comprises the clinical nursing path template of at least two different therapeutic modalities.
A kind of electronic clinical nursing path management method, comprising:
There is provided a server, described server has a database, described database purchase have patient's diagnostic message, medical record information, with based on diagnosing the clinical nursing path template set up; Described clinical nursing path template comprises timing node and the nursing content corresponding with each timing node;
Clinical nursing path template described in the typing of office terminal, and described clinical nursing path template is uploaded in the database of described server;
Medical care terminal obtains diagnosing patient information from the database of described server, from described database, adaptive clinical nursing path template is selected to set up the actual clinical nursing path of this patient according to described diagnosing patient information, and automatically record the implementation status of described actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database of described server;
Office terminal carries out monitoring management according to described implementation status, nursing situation and result to described actual clinical nursing path.
The invention has the beneficial effects as follows: electronic clinical nursing path management system provided by the invention and method, the office terminal that the supvrs such as the medical care terminal use charge nurse and charge nurse use is connected with server communication, the database purchase of server has the clinical nursing path template of case and this case, and clinical nursing path template comprises timing node and the nursing content corresponding with each timing node.In patient care process, the clinical nursing path template that the supvrs such as charge nurse can be set up based on diagnosis by office terminal typing, and clinical nursing path template is uploaded in the database of described server.Charge nurse can obtain diagnosing patient information by medical care terminal from the database of server, from database, select adaptive clinical nursing path template to set up the actual clinical nursing path of this patient according to diagnosing patient information, charge nurse performs the nursing content etc. of each timing node again according to this actual clinical nursing path.Meanwhile, medical care terminal can also record the implementation status of actual clinical nursing path, nursing situation and result, synchronously completes corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database of described server.Supvr obtains described implementation status, nursing situation and result by office terminal, and monitors according to implementation status, nursing situation and the result actual clinical nursing path to patient.So, effective execution of patients clinical nursing path can be realized.Meanwhile, supvr the actual clinical nursing path to patient can carry out management maintenance according to nursing situation and result, to reduce the generation of variation situation.In addition, automatically can generate the NN list of the execution list in whole flow process, nursing situation and result, meet electronization, sheet format record and normalized written requirement etc.Further, Quality Control can also be carried out to whole execution flow process, when detecting that the essential nursing content of the upper timing node in described actual clinical nursing path does not perform, control the future time node that described NN module can not enter actual clinical nursing path, so, the accurate execution in path can be guaranteed, improve quality of medical and nursing etc.
Accompanying drawing explanation
Fig. 1 is the structural representation of embodiment of the present invention electronization clinical nursing path management system;
Fig. 2 is the structural representation of medical care terminal in embodiment of the present invention electronization clinical nursing path management system;
Fig. 3 is the structural representation of office terminal in embodiment of the present invention electronization clinical nursing path management system;
Fig. 4 is the structural representation of the path management module of office terminal in embodiment of the present invention electronization clinical nursing path management system;
Fig. 5 is the process flow diagram of embodiment of the present invention electronization clinical nursing path management method.
The realization of the object of the invention, functional characteristics and advantage will in conjunction with the embodiments, are described further with reference to accompanying drawing.
Embodiment
Be described below in detail embodiments of the invention, the example of described embodiment is shown in the drawings, and wherein same or similar label represents same or similar element or has element that is identical or similar functions from start to finish.Be exemplary below by the embodiment be described with reference to the drawings, be intended to for explaining the present invention, and can not limitation of the present invention be interpreted as.
With reference to shown in Fig. 1, embodiments provide a kind of electronic clinical nursing path management system, comprise server 100, office terminal 200 and medical care terminal 300.
Server 100 has a database 101, described database 101 store automatically uploaded by doctor workstation diagnosing patient information, medical record information, with based on diagnosing the clinical nursing path template set up; Described clinical nursing path template comprises timing node and the nursing content corresponding with each timing node;
Certainly, be understandable that, the database 101 of server 100, nursing situation and result that clinical nursing path template corresponding to each case reach can also be stored.So that as the reference of follow-up case treatment and nursing.
Be understandable that, clinical nursing path template corresponding to same case can comprise the clinical nursing path template of at least two different therapeutic modalities.Concrete, the different therapeutic modalities taked for same diagnosis.Namely same case (diagnostic message is identical), can adopt different therapeutic modalities, each therapeutic modality correspondence establishment clinical nursing path template, to adapt to the sick human needs of nursing different therapeutic modality.
Medical care terminal 300 is connected by described communication network with described server 100, for obtaining diagnosing patient information in the database 101 from described server 100, from described database, adaptive clinical nursing path template is selected to set up the actual clinical nursing path of this patient according to described diagnosing patient information, and automatically record the implementation status of described actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database 101 of described server 100.
Concrete, when after patient admission, after being diagnosed by the doctor in charge, diagnosing patient information uploads onto the server in the database 101 of 100 by doctor workstation automatically.This diagnosing patient information can be such as disease name (unstable angina, coronary heart disease, diabetes etc.) and modus operandi etc.And charge nurse is again by medical care terminal 300 automatic acquisition diagnosing patient information, for the patient needing access path, medical care terminal 300 goes out adaptive clinical nursing path template by according to the case in the database 101 of server 100 and clinical nursing path template matches, and the actual clinical nursing path of this patient after being confirmed by charge nurse, is set up based on this clinical nursing path template, because the concrete condition of each patient is not necessarily identical, therefore, after medical care terminal 300 matches adaptive clinical nursing path template, the supvrs such as charge nurse can do accommodation amendment, to set up actual clinical nursing path.Certainly, this actual clinical nursing path is also comprise timing node and nursing content corresponding to each timing node, and the supvrs such as charge nurse can regulation time node and/or nursing content.
In conjunction with the section office of hospital, electronic clinical nursing path management system of the present invention can arrange multiple medical care terminal 300, concrete, such as each section office can configure at least one medical care terminal 300, internal medicine, surgery, orthopaedics, gynaecology, obstetrics, paediatrics, ophthalmology, dept. of dermatology, oncology etc.Above-mentioned medical care terminal 300 can be the terminal that desk-top computer or notebook computer etc. have data processing energy.When after the actual clinical nursing path setting up patient, charge nurse can start to perform this actual clinical nursing path, is patient and arranges corresponding nursing content.After starting execution, namely medical care terminal 300 starts automatically to record the implementation status of described actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database 101 of described server 100.The implementation status such as such as execution time, personnel, execution content, and the nursing situation such as physical condition of patient after performing and result.
Office terminal 200 is connected by communication network 400 with described server 100, for clinical nursing path template described in typing, and described clinical nursing path template be uploaded in the database 101 of described server 100, and according to described implementation status, nursing situation and result, monitoring management is carried out to described actual clinical nursing path.
This office terminal 200 is generally operated by charge nurse or other supvrs through authorizing, and can be the terminal that desk-top computer or notebook computer etc. have data processing energy.The supvrs such as charge nurse can establish the various clinical nursing path masterplate based on diagnosis in advance by this office terminal 200, and by above-mentioned for clinical nursing path masterplate in the database 101 of server 100.
This clinical nursing path template is the standardized therapeutic pattern and scheme formulated for certain case, specifically, this clinical nursing path template take time as transverse axis, nursing content is the work dimension of the longitudinal axis, wherein, based on the overall process that timing node is left hospital Zi being admitted to hospital to by inpatient, find critical period as timing node, write the nursing content of each timing node respectively, such as surgical departments design node is: be admitted to hospital day-operation consent-Post operation-convalescence-leave hospital day, Non-operation departments design node for be admitted to hospital day-be in hospital (such as 2-3 days)-leave hospital before-leave hospital day etc.And nursing content to write with care program be thinking, be that clue is progressively launched according to assessment, nursing emphasis, nursing intervention, health education, form the nursing content of each timing node.For the patient of multiple complication and existence, potential multiple nursing problem, the nursing content of each timing node can be divided into again some sub-dimensions, comprise routine care work, basic nursing assessment and measure, specific nursing assessment and measure, health education/rehabilitation guide, special care record etc., in every sub-dimension, write concrete nursery work content according to the thinking of care program again.The related data of above-mentioned pertinent clinical nursing path can by the supvrs such as charge nurse typing on office terminal, and upload onto the server 100 database 101 in store, so that as the reference template of later stage Case treatment nursing.
With reference to shown in Fig. 2, in one particular embodiment of the present invention, medical care terminal 300 comprises data obtaining module 301, module 302 is set up in path, NN module 303, and wherein, data obtaining module 301 is for obtaining the diagnosing patient information of patient from described server 100.
Module 302 is set up for according to described diagnosing patient information in path, the clinical nursing path template suitable with described diagnosing patient information is matched from the database 101 of described server 100, and set up the actual clinical nursing path of this patient according to this clinical nursing path template, and described actual clinical nursing path is stored in the database 101 of described server 100.That is, medical care terminal 300 can obtain diagnosing patient information by data obtaining module 301 from the database 101 of server 100.Module 302 is set up according to described diagnosing patient information again by path, the clinical nursing path template suitable with described diagnosing patient information is matched from the database 101 of described server 100, and set up the actual clinical nursing path of this patient according to this clinical nursing path template, and described actual clinical nursing path is stored in the database 101 of described server 100.Such as current patient is diagnosed as unstable angina, then the clinical nursing path template that module 302 matches unstable angina case and correspondence from the database 101 of server 100 is set up in path, actual clinical nursing path is set up again according to this clinical nursing path template, and set up patient files, such as admission number, bed label, patient name, sex, section office's title, doctor's title, the access path time, path time current point in time, when prosthomere, exit path time, clinical nursing path title etc.
NN module 303 performs the implementation status of described actual clinical nursing path, nursing situation and result for automatically recording, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database 101 of described server 100.After the actual clinical nursing path of patient is set up, after medical personnel click " execution " in medical care terminal 300, NN module 303 starts timing from first timing node, and meanwhile, charge nurse can arrange the nursing content of each timing node for patient.In the process of implementation, NN module 303 also records the implementation status such as execution time, personnel, execution content automatically, and the nursing situation such as physical condition of patient after performing and result, synchronously completes corresponding NN.
In a preferably embodiment of the present invention, medical care terminal 300 also comprises quality inspection control module 304, this quality inspection control module 304 is for the implementation status of actual clinical nursing path described in monitor and detection, when detecting that the essential nursing content of the upper timing node in described actual clinical nursing path does not perform, control the future time node that described NN module 303 can not enter actual clinical nursing path.Due to, NN module 303 can record the implementation status such as execution time, personnel, execution content automatically, and the nursing such as physical condition situation and the result etc. of patient after performing, so, can be monitored by quality inspection control module 304 pairs of NN modules 303, if the nursing content of a upper timing node does not perform or do not complete, then NN module 303 can not enter future time node.So, can realize carrying out Quality Control to whole execution flow process, the accurate execution in path can be guaranteed, improve quality of medical and nursing etc.
With reference to shown in Fig. 3, in one particular embodiment of the present invention, office terminal 200 comprises typing module 201 and path management module 202, and described clinical nursing path template for typing clinical nursing path template, and is uploaded in the database 101 of described server 100 by typing module 201.Path management module 202 for obtaining described implementation status, nursing situation and result from server 100, and according to described implementation status, nursing situation and result to the actual clinical nursing path monitoring management of patient.Namely, this path management module 202 obtains medical care terminal 300 from server 100 and records and the implementation status such as the execution time of uploading, personnel, execution content, and the nursing situation such as physical condition of patient after performing and result.Again according to implementation status, nursing situation and the actual clinical nursing path of result to patient carry out monitoring management maintenance, such as, revise the actual clinical nursing path etc. of patient.
With reference to shown in Fig. 4, specifically, path management module 202 can comprise statistical module 2021 and revision module 2022, statistical module 2021 is for obtaining described nursing situation and result from server 100, and by described nursing situation and result and situation is nursed in expection and result contrasts, judge whether described nursing situation and result morph.Revision module 2022, for when described nursing situation and result morph, is modified to the actual clinical nursing path of described patient.Under normal circumstances, the actual clinical path of patient normally performs, and gets a desired effect, and performs to leaving hospital day, then normally can go out footpath, and midway does not need to modify to actual clinical nursing path or adjustment etc., but at some in particular cases, in the process performed according to actual clinical nursing path, fall flat or morph, then can not continue to perform according to actual clinical nursing path, need to carry out actual clinical nursing path by revision module 2022 according to variation situation modify or adjust, the nursing content of such as modification time node or exit current actual clinical nursing path and set up new path, produce this actual clinical nursing path again or first, proceed to a new actual clinical nursing path again, finally proceed to this actual clinical nursing path etc. again.
In an embodiment of invention, office terminal 200 also comprises list generation module 203, and this list generation module 203 is for generating the NN list of the execution list of actual clinical nursing path, nursing situation and result.So, be convenient to keeper and monitor the execution of patient's actual clinical nursing path and nursing situation etc., meanwhile, the mode of this automatic generation, meets electronization, sheet format record and normalized written requirement etc.
In another embodiment of the invention, office terminal 200 also comprises authority management module 204, for managing the authority of the actual clinical nursing path of patient being carried out to the user of management maintenance.Because the determination of the actual clinical nursing path of patient has preciseness and science, therefore, limited by the rights management of authority management module 204 couples of users, then improve the quality of medical treatment and nursing.
In one embodiment of the invention, office terminal 200 also comprises list binding module 205.This list binding module 205 for predetermined time node is needed write specific Nursing recording list single class and described predetermined time node in addition " binding ", during to make this timing node of execution, automatically can enter into the NN list of predetermined type.Namely, the supvrs such as charge nurse can need to write specific Nursing recording list single class by list binding module 205 this timing node of the upper binding of certain timing node (predetermined time node) in the actual clinical nursing path of patient, so, when medical care terminal 300 performs to this timing node position, the NN list that automatically can enter into the NN list of this kind (predetermined type) starts record.Simultaneously, this list binding module 205 is also for needing to write the observation item of specific NN content and described default timing node in addition " binding " by default timing node, to make when performing this timing node, automatically the observation item preset is entered into, record is carried out to it, with the NN of generating standard.Namely, the supvrs such as charge nurse can need the observation item of monitoring by list binding module 205 this timing node of the upper binding of certain timing node (predetermined time node) in the actual clinical nursing path of patient, so, when medical care terminal 300 performs to this timing node position, automatically can enter into the observation item preset, record is carried out to it.
Being understandable that, each functional module that above-mentioned medical care terminal 300 and office terminal 200 comprise, can be hardware or the software module of this terminal device.
With reference to shown in Fig. 5, the embodiment of the present invention additionally provides a kind of electronic clinical nursing path management method, comprising:
S101, provide a server, described server has a database, the clinical nursing path template that described database purchase has patient's diagnostic message, medical record information and sets up based on diagnosis; Described clinical nursing path template comprises timing node and the nursing content corresponding with each timing node;
Clinical nursing path template described in S102, office terminal typing, and described clinical nursing path template is uploaded in the database of described server.
S103, medical care terminal obtain diagnosing patient information from the database of described server, from described database, adaptive clinical nursing path template is selected to set up the actual clinical nursing path of this patient according to described diagnosing patient information, and automatically record the implementation status of described actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database of described server.
S104, office terminal carry out monitoring management according to described implementation status, nursing situation and result to described actual clinical nursing path.
The method of the present embodiment is applicable to the electronic clinical nursing path management system of the embodiment of the present invention, its each steps flow chart, can be realized, be not described in detail at this by terminal corresponding to electronic clinical nursing path management system or module.
In sum, electronic clinical nursing path management system provided by the invention and method, the office terminal 200 that the supvrs such as the medical care terminal 300 use charge nurse and charge nurse use communicates to connect with server 100, the database 101 of server 100 stores the clinical nursing path template of case and this case, and clinical nursing path template comprises timing node and the nursing content corresponding with each timing node.In patient care process, clinical nursing path template by the clinical nursing path template of office terminal 200 typing based on diagnosis, and can be uploaded in the database 101 of described server 100 by the supvrs such as charge nurse.Charge nurse can obtain diagnosing patient information by medical care terminal 300 from the database 101 of server 100, from database 101, select adaptive clinical nursing path template to set up the actual clinical nursing path of this patient according to diagnosing patient information, charge nurse performs the nursing content etc. of each timing node again according to this actual clinical nursing path.Simultaneously, medical care terminal can also record the implementation status of actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database 101 of described server 100.Supvr obtains described implementation status, nursing situation and result by office terminal 200, and monitors according to implementation status, nursing situation and the result actual clinical nursing path to patient.So, effective execution of patients clinical nursing path can be realized.Meanwhile, supvr the actual clinical nursing path to patient can carry out management maintenance according to nursing situation and result, to reduce the generation of variation situation.In addition, automatically can generate the NN list of the execution list in whole flow process, nursing situation and result, meet electronization, sheet format record and normalized written requirement etc.Further, Quality Control can also be carried out to whole execution flow process, when detecting that the essential nursing content of the upper timing node in described actual clinical nursing path does not perform, control the future time node that described NN module can not enter actual clinical nursing path, so, the accurate execution in path can be guaranteed, improve quality of medical and nursing etc.
In the description of this instructions, specific features, structure, material or feature that the description of reference term " embodiment ", " some embodiments ", " example ", " concrete example " or " some examples " etc. means to describe in conjunction with this embodiment or example are contained at least one embodiment of the present invention or example.In this manual, identical embodiment or example are not necessarily referred to the schematic representation of above-mentioned term.And the specific features of description, structure, material or feature can combine in an appropriate manner in any one or more embodiment or example.
Although illustrate and describe embodiments of the invention above, be understandable that, above-described embodiment is exemplary, can not be interpreted as limitation of the present invention, those of ordinary skill in the art can change above-described embodiment within the scope of the invention when not departing from principle of the present invention and aim, revising, replacing and modification.
Claims (10)
1. an electronic clinical nursing path management system, is characterized in that, comprising:
Server, described server has a database, the clinical nursing path template that database purchase has patient's diagnostic message, medical record information and sets up based on diagnosis; Described clinical nursing path template comprises timing node and the nursing content corresponding with each timing node;
Medical care terminal, described medical care terminal is connected by described communication network with described server, for obtaining diagnosing patient information in the database from described server, from described database, adaptive clinical nursing path template is selected to set up the actual clinical nursing path of this patient according to described diagnosing patient information, and automatically record the implementation status of described actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and this implementation status, nursing situation and result, NN are uploaded to the database of described server;
Office terminal, described office terminal is connected by communication network with described server, for clinical nursing path template described in typing, and described clinical nursing path template be uploaded in the database of described server, and according to described implementation status, nursing situation and result, monitoring management is carried out to described actual clinical nursing path.
2. electronic clinical nursing path management system according to claim 1, is characterized in that, described medical care terminal comprises:
Data obtaining module, for obtaining the diagnosing patient information of patient from described server;
Module is set up in path, for according to described diagnosing patient information, the clinical nursing path template suitable with described diagnosing patient information is matched from the database of described server, and set up the actual clinical nursing path of this patient according to this clinical nursing path template, and described actual clinical nursing path is stored in the database of described server;
NN module, for automatically recording the implementation status, nursing situation and the result that perform described actual clinical nursing path, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database of described server.
3. electronic clinical nursing path management system according to claim 2, is characterized in that, described medical care terminal also comprises:
Quality inspection control module, for the implementation status of actual clinical nursing path described in monitor and detection, when detecting that the essential nursing content of the upper timing node in described actual clinical nursing path does not perform, control the future time node that described NN module can not enter actual clinical nursing path.
4. electronic clinical nursing path management system according to claim 2, it is characterized in that, described office terminal comprises:
Typing module, for typing clinical nursing path template, and is uploaded in the database of described server;
Path management module, for obtaining described implementation status, nursing situation and result, and according to described implementation status, nursing situation and result to the actual clinical nursing path monitoring management of patient from server.
5. electronic clinical nursing path management system according to claim 4, it is characterized in that, described path management module comprises:
Statistical module, for obtaining described nursing situation and result from server, and by described nursing situation and result and situation is nursed in expection and result contrasts, judges whether described nursing situation and result morph;
Revision module, for when described nursing situation and result morph, modifies to the actual clinical nursing path of described patient.
6. electronic clinical nursing path management system according to claim 4, it is characterized in that, described office terminal also comprises:
List generation module, for generating the NN list of the execution list of actual clinical nursing path, nursing situation and result.
7. electronic clinical nursing path management system according to claim 4, it is characterized in that, described office terminal also comprises:
List binding module, for predetermined time node is needed write specific Nursing recording list single class and described predetermined time node in addition " binding ", during to make this timing node of execution, automatically can enter into the NN list of predetermined type;
And need default timing node to write the observation item of specific NN content and described default timing node in addition " binding ", to make when performing this timing node, automatically enter into the observation item preset, record is carried out to it, with the NN of generating standard.
8. electronic clinical nursing path management system according to claim 4, it is characterized in that, described office terminal also comprises:
Authority management module, for managing the authority of the actual clinical nursing path of patient being carried out to the user of management maintenance.
9. electronic clinical nursing path management system according to claim 1, is characterized in that, clinical nursing path template corresponding to same case comprises the clinical nursing path template of at least two different therapeutic modalities.
10. an electronic clinical nursing path management method, is characterized in that, comprising:
There is provided a server, described server has a database, the clinical nursing path template that described database purchase has patient's diagnostic message, medical record information and sets up based on diagnosis; Described clinical nursing path template comprises timing node and the nursing content corresponding with each timing node.
Clinical nursing path template described in the typing of office terminal, and described clinical nursing path template is uploaded in the database of described server;
Medical care terminal obtains diagnosing patient information from the database of described server, from described database, adaptive clinical nursing path template is selected to set up the actual clinical nursing path of this patient according to described diagnosing patient information, and automatically record the implementation status of described actual clinical nursing path, nursing situation and result, synchronously complete corresponding NN, and by this implementation status, nursing situation and result, Nursing recording list single upload to the database of described server;
Office terminal carries out monitoring management according to described implementation status, nursing situation and result to described actual clinical nursing path.
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| CN (1) | CN104408329A (en) |
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| CN106777895A (en) * | 2016-11-23 | 2017-05-31 | 北京汉博信息技术有限公司 | Standardization surgical procedure data creation method |
| CN106846206A (en) * | 2017-01-18 | 2017-06-13 | 泰康保险集团股份有限公司 | Nursing system and nursing process monitoring method |
| CN107157678A (en) * | 2017-04-28 | 2017-09-15 | 邓晶晶 | A kind of nursing path management system and method based on intelligent bedside cabinet |
| CN107196993A (en) * | 2017-04-17 | 2017-09-22 | 新乡医学院 | Electronic clinical nursing path management system and method |
| CN107423559A (en) * | 2017-06-16 | 2017-12-01 | 康美健康云服务有限公司 | A kind of client-based disease control method and its system |
| CN107958262A (en) * | 2017-11-07 | 2018-04-24 | 湖南明康中锦医疗科技发展有限公司 | Comprehensive care platform, the method for comprehensive care and storage medium |
| CN108257663A (en) * | 2018-01-05 | 2018-07-06 | 杨莉 | Electronic clinical nursing path manages system |
| CN109949889A (en) * | 2019-03-29 | 2019-06-28 | 镇江市第一人民医院 | A kind of Nursing Electronic medical records system |
| CN111261268A (en) * | 2020-01-13 | 2020-06-09 | 广元市中心医院 | Interactive whiteboard information publishing system and using method thereof |
| CN111524585A (en) * | 2020-04-24 | 2020-08-11 | 一选(浙江)医疗科技有限公司 | Automatic quality control management system and method for severe medical science department |
| CN112086179A (en) * | 2020-09-10 | 2020-12-15 | 上海市第十人民医院 | ERAS clinical pathway system |
| CN112349365A (en) * | 2020-11-02 | 2021-02-09 | 山东华码软件有限公司 | Whole-course tracking system for treatment information of surgical operation patient |
| CN113539504A (en) * | 2021-06-29 | 2021-10-22 | 兰州大学第一医院 | Clinical path information management system and method based on big data |
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Cited By (15)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN106777895A (en) * | 2016-11-23 | 2017-05-31 | 北京汉博信息技术有限公司 | Standardization surgical procedure data creation method |
| CN106846206A (en) * | 2017-01-18 | 2017-06-13 | 泰康保险集团股份有限公司 | Nursing system and nursing process monitoring method |
| CN106846206B (en) * | 2017-01-18 | 2021-04-13 | 泰康保险集团股份有限公司 | Nursing system and nursing process monitoring method |
| CN107196993B (en) * | 2017-04-17 | 2020-01-24 | 新乡医学院 | Electronic clinical nursing path management system and method |
| CN107196993A (en) * | 2017-04-17 | 2017-09-22 | 新乡医学院 | Electronic clinical nursing path management system and method |
| CN107157678A (en) * | 2017-04-28 | 2017-09-15 | 邓晶晶 | A kind of nursing path management system and method based on intelligent bedside cabinet |
| CN107423559A (en) * | 2017-06-16 | 2017-12-01 | 康美健康云服务有限公司 | A kind of client-based disease control method and its system |
| CN107958262A (en) * | 2017-11-07 | 2018-04-24 | 湖南明康中锦医疗科技发展有限公司 | Comprehensive care platform, the method for comprehensive care and storage medium |
| CN108257663A (en) * | 2018-01-05 | 2018-07-06 | 杨莉 | Electronic clinical nursing path manages system |
| CN109949889A (en) * | 2019-03-29 | 2019-06-28 | 镇江市第一人民医院 | A kind of Nursing Electronic medical records system |
| CN111261268A (en) * | 2020-01-13 | 2020-06-09 | 广元市中心医院 | Interactive whiteboard information publishing system and using method thereof |
| CN111524585A (en) * | 2020-04-24 | 2020-08-11 | 一选(浙江)医疗科技有限公司 | Automatic quality control management system and method for severe medical science department |
| CN112086179A (en) * | 2020-09-10 | 2020-12-15 | 上海市第十人民医院 | ERAS clinical pathway system |
| CN112349365A (en) * | 2020-11-02 | 2021-02-09 | 山东华码软件有限公司 | Whole-course tracking system for treatment information of surgical operation patient |
| CN113539504A (en) * | 2021-06-29 | 2021-10-22 | 兰州大学第一医院 | Clinical path information management system and method based on big data |
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