CN111145889A - Intelligent nursing shift-switching system based on clinical decision support system - Google Patents
Intelligent nursing shift-switching system based on clinical decision support system Download PDFInfo
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Abstract
The invention provides an intelligent nursing shift-switching system based on a clinical decision support system, which comprises terminal equipment and a server, wherein the server is used for receiving patient data from each clinical information system, analyzing, integrating and comparing the patient data with knowledge in a knowledge base, and generating shift-switching information of a visual man-machine interaction end through an inference machine; the terminal equipment is used for displaying shift information; the terminal equipment comprises a nurse station computer PC end and a mobile handheld PDA; the shift information comprises 3 presentation forms, including an intelligent shift report of a nurse station computer PC end, a whole ward information board of the nurse station computer PC end and a single patient information board of a mobile handheld PDA end. The invention can help nurses to quickly, comprehensively and accurately master the general situation of the whole ward area when the nurses change shift, identify high-risk people, perform the most suitable shift-changing decision, help nursing managers to reasonably arrange the work of the ward area, allocate the human resources, ensure the smooth and orderly work of the ward area, and enable the shift-changing to be more quick and efficient.
Description
Technical Field
The invention belongs to the technical field of hospital management, and particularly relates to an intelligent nursing shift-switching system based on a clinical decision support system.
Background
The shift is a daily and frequent nursing work task for nurses, the shift is performed for a plurality of times every day, a plurality of patients are shifted each time, clinical information of each patient is changed in real time, shift work scenes are changed during shift (bedside shift is performed one-to-one, and the shift is performed in a centralized manner at a nurse station), and a great amount of accurate information needs to be mastered during shift. If the traditional mode is adopted for shift, the missing or error of the patient information is very easy to cause, and researches show that more than half of medical error events are caused by the loss of information transmission among medical care personnel.
Nurses need to quickly, comprehensively and accurately master the general situation of the whole disease area when handing over to work and identify high-risk groups; but also to realize accurate, complete and convenient information transmission during bedside handover; the degree of excellence or disadvantage depends on whether the nurse can efficiently access, process and use a series of information. Therefore, an intelligent nursing shift-switching system which takes nurse demands as a center, fully considers the diversity of work scenes and work flows of nurses, helps nurses to improve the capabilities of information collection, sorting, classification and filtering during shift switching and supports nurse shift switching is urgently needed.
In the prior art, application of data homology nursing shift-switching report software such as response wave and the like and application of an information nursing shift-switching system such as king cool and the like can improve the writing efficiency of shift-switching reports. But still can not meet the information requirement of the diversity of the nurse shift process and lacks decision support assistance in the process of converting the nurse shift working scene.
Disclosure of Invention
The invention aims to overcome the defects of the prior art and provides an intelligent nursing shift-switching system based on a clinical decision support system, which can be used for assisting nurses to carry out shift switching in multiple scenes (centralized shift switching at nurse stations and one-to-one shift switching at bedside) under the diversified requirements of working scenes and working flows during the shift switching of the nurses, efficiently acquiring accurate information, and simultaneously inputting shift switching information by multiple terminals so as to improve the shift switching quality and the shift switching efficiency and realize the clinical decision support assisting nurses to carry out shift switching with multiple points and multiple problems;
the second purpose of the invention is to provide an intelligent nursing shift-switching method based on a clinical decision support system.
The invention adopts the following technical scheme:
an intelligent nursing shift-switching system based on a clinical decision support system comprises terminal equipment and a server, wherein the server is used for receiving patient data from each clinical information system, analyzing, integrating and comparing the patient data with knowledge in a knowledge base, and generating shift-switching information of a visual man-machine interaction end through an inference machine; the terminal equipment is used for inputting patient data and displaying shift information.
Further, the terminal device is in wireless communication connection with the server.
Further, the terminal equipment comprises a nurse station computer PC end and a mobile handheld PDA.
Further, the shift information includes 3 presentation forms: intelligent shift report of nurse station computer PC end: presenting shift information of patients in the ward in a table form; nurse station computer PC end's full ward information billboard: the system is used for presenting critical information of the ward area concerned by the nursing visual angle; single patient information billboard at mobile handheld PDA end: the system is used for presenting key information of a single patient during one-to-one shift, including basic information, nursing assessment and important state information of the patient.
Further, the patient data includes: basic information of the patient, including specifically the bed number, name, hospital number, sex, age, care level, diet, and major diagnosis; patient flow information, including in particular admission, discharge, death, diversion, surgery and delivery; the patient's vital signs data, including vital signs, symptom sign records and examination results; the main diagnosis and treatment records of the patient specifically comprise executive records of doctors and nurses.
Furthermore, the intelligent shift-switching report of the PC end of the nurse station presents the shift-switching information of the patients in the ward in a tabular form, and provides the functions of page editing, saving, deleting, looking up and printing.
Further, the full ward information billboard of nurse station computer PC end is updated in real time, divides 2 parts from top to bottom, and the first half shows a plurality of icon, is aided with the characters simultaneously, presents as icon + characters + patient number, and when the nurse clicked the icon of first half, the second half can show the detailed information of the patient that this icon corresponds.
Furthermore, the single-patient information billboard at the mobile handheld PDA end comprises four information areas, including patient basic data, nursing assessment, important states and manual remarking areas; when the patient is in one-to-one shift at the bedside, the key information of the single patient is presented in four information areas, and the basic information, the nursing evaluation and the important state data of the patient are automatically collected, sorted, classified, filtered and presented by a system server according to the rules of a knowledge base.
An intelligent nursing shift-switching method based on a clinical decision support system comprises the following steps:
s1, before the shift, a plurality of responsible nurses can input shift information through a plurality of computer hosts at the same time, the data system of the information board of the whole ward area in the computer hosts of the nurse station is automatically updated in real time, and the latest data is automatically updated by the information board of a single patient 15 minutes before the shift; before the shift, the shift nurse inputs shift content into a manual remarking area of a single patient information billboard according to the illness state of a patient and the actual nursing work requirement;
s2, when the nurse station centrally hands over, the nursing manager reasonably arranges human resources according to the information of the whole ward area, and the nurse taking over the work can display the detailed information of the patient corresponding to the icon by calling the intelligent shift report and logging in the information board of the whole ward area of the nurse station and clicking the icon, so that the distribution of the bed number and the state of the patient of the high-risk patient in the ward area can be known, the general situation of the whole ward area can be mastered, and the high-risk group can be identified;
s3, when the bedside one-to-one shift is carried out, the nurse transfers the patient data, the nursing evaluation and the important state comprehensively through the single patient information billboard at the mobile handheld PDA end, and simultaneously, the information in the remarking area of the single patient information billboard can be modified or recorded at any time according to the transfer condition.
The invention has the beneficial effects that:
(1) according to the intelligent nursing shift-switching system based on the clinical decision system, the summary information of the patients is automatically counted by utilizing an information technology, the basic information of the patients is automatically extracted, objective data in an electronic medical record and a diagnosis and treatment record are directly called, and the shift-switching information omission and errors caused by manual lookup of nurses are avoided; the system has the function of simultaneously inputting by a plurality of terminals, so that different responsibility nurses can simultaneously record shift information, and shift is more rapid and efficient;
(2) the informationized billboard of the nurse station is updated in real time, so that nurses can quickly, comprehensively and accurately master the general situation of the whole disease area, identify high-risk people and make the most suitable decision of handing over to shift; the nursing management personnel can be helped to reasonably arrange the work of the ward, the allocation of human resources is carried out, and the smooth and orderly work of the ward is ensured;
(3) according to the single-patient information billboard of the mobile handheld terminal, the data system server automatically collects, arranges, classifies, filters and presents according to the rules of the knowledge base, meanwhile, the personalized requirements are considered, the single-patient information billboard has a manual input function, the accurate, complete and convenient service target of information transmission can be realized when a bedside is handed over, nurses are helped to know the current state of patients, nursing problems are identified, complications are prevented and responded, and the aims of improving nursing quality and improving the outcome of the patients are finally realized.
Description of the drawings:
FIG. 1 is a diagram of a system model of the present invention;
FIG. 2 is a structural diagram of a full ward information billboard of a computer host of a nurse station;
FIG. 3 is a structural diagram of a single-patient information billboard at the mobile handheld PDA end of the invention;
fig. 4 is a flow chart of the nurse's shift of the present invention.
The specific implementation mode is as follows:
in order to make the objects, technical solutions and advantages of the embodiments of the present invention clearer, the technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the drawings in the embodiments of the present invention, and it is obvious that the described embodiments are some, but not all, embodiments of the present invention. All other embodiments, which can be obtained by a person skilled in the art without any inventive step based on the embodiments of the present invention, are within the scope of the present invention.
As shown in fig. 1, the invention provides an intelligent nursing shift-switching system based on a clinical decision support system, which comprises a terminal device and a server, wherein the server is used for receiving patient data from each clinical information system, analyzing, integrating and comparing the patient data with knowledge of a knowledge base, and generating shift-switching information of a visual human-computer interaction terminal through an inference machine; patient data is from a hospital information platform, various clinical systems such as a nursing information system, an electronic medical record, an operation anesthesia system, a checking system, an image system and the like are integrated, all medical record information including basic patient information, diagnosis and treatment information, nursing information, examination and inspection information, operation information, charging information and the like of a patient from admission to discharge of the patient is called in real time by using a patient main index, corresponding matching and calculation are carried out according to requirements, and the accuracy of the data is ensured; the terminal equipment is used for inputting patient data and displaying shift information; the terminal equipment is in wireless communication connection with the server; the terminal equipment comprises a nurse station computer PC end and a mobile handheld PDA.
The shift-changing information of the invention comprises 3 presentation forms: intelligent shift report of nurse station computer PC end: presenting shift information of patients in the ward in a table form; nurse station computer PC end's full ward information billboard: the system is used for presenting critical information of the ward area concerned by the nursing visual angle; single patient information billboard at mobile handheld PDA end: the system is used for presenting key information of a single patient during one-to-one shift, including basic information, nursing assessment and important state information of the patient.
Specifically, the server may automatically extract patient data of each clinical information system, where the patient data includes: basic information of the patient, including specifically the bed number, name, hospital number, sex, age, care level, diet, and major diagnosis; patient flow information, including in-hospital, out-hospital, death, diversion, surgery, and childbirth, among others; the patient's vital signs data, including vital signs, symptom sign records and examination results; the main diagnosis and treatment records of the patient specifically comprise executive records of doctors and nurses; the server automatically counts the summary information of the patients who change their shifts every time, the nurse can selectively call the life index data of the patients and the main diagnosis and treatment records of the patients in the clinical information system, and the system can provide sentences matched with the categories according to the categories of the patients to assist the nurse in making a shift decision.
In the invention, the intelligent shift-switching report of the PC end of the nurse station presents the shift-switching information of patients in the ward in a tabular form and provides the functions of page editing, saving, deleting, looking up and printing;
as shown in figure 2, the whole ward information billboard at the PC end of the nurse station can be updated in real time and is divided into an upper part and a lower part, and responsibility nurses and nursing managers can know the bed number distribution and the patient state of high-risk patients in the ward through the whole ward information billboard and quickly acquire classification information.
According to actual requirements, the upper half part of the whole ward information billboard presents the ward key information items concerned by nursing visual angles by a plurality of icons, and presents the ward key information items as icons, characters and patient numbers by being assisted by simple characters; specifically, the icon may be: evaluating high-risk items and the number of corresponding patients, wherein the evaluation score of the risk factors of the pressure injury is less than or equal to 12 points, and the evaluation score of the risk factors of falling down from the bed is more than or equal to 1 point; artificial pipeline items such as tracheal passages, vascular passages, ureters, gastrointestinal tubes and the like and the number of corresponding patients; testing items such as special blood types and drug-resistant bacteria infection and the like and the number of corresponding patients; the number of patients and surgical items such as the current surgery, the tomorrow planning surgery, the day surgery and the like; and (4) reporting nursing safety items such as stress injury reporting, incontinence-related dermatitis reporting and venous thromboembolism reporting and the number of patients. The whole ward information billboard lower half part displays the numbered slips information of the ward patients, when the nurse clicks the icon of the upper half part, the lower half part can display the detailed information of the patients corresponding to the icon, and the nurse is supported to quickly, comprehensively and accurately grasp the general situation of the whole ward patients when the nurse station performs centralized shift.
As shown in fig. 3, clicking any patient in the patient list in the handheld mobile PDA end can enter the single-patient information billboard of the patient; the single-patient information billboard at the mobile handheld PDA end comprises four information areas, including basic patient data, nursing assessment, important states and manual remarking areas; when the patient is in one-to-one shift at the bedside, the key information of the single patient is presented in four information areas, and the basic information, the nursing evaluation and the important state data of the patient are automatically collected, sorted, classified, filtered and presented by a system server according to the rules of a knowledge base. The condition of a patient and key information can be mastered by the nursing informatization billboard of the dimension of the patient without looking up the medical record of each patient.
Specifically, the single-patient information billboard comprises four information areas, wherein the patient basic information area presents general information of the patient, including information such as bed number, name, hospital number, sex, age, nursing grade, diet and diagnosis, and displays the risk/severity of illness by using different colors; the nursing evaluation area presents positive evaluation results of nurses on patients, wherein the positive evaluation results comprise vital signs, 24 h input and output, nursing scores, high-risk states, abnormal inspection results and the like; the important state area presents information such as no artificial pipeline, operation mode, special inspection and the like; in the manual remarking area, a nurse can automatically input related contents according to the patient's condition and the special nursing work requirement.
Referring to fig. 4, the present invention further provides an intelligent nursing shift-switching method based on a clinical decision support system, including the following steps:
s1, the shift nurse logs in the nurse shift report module before the shift, and finishes the written shift report of the shift according to the shift group sentence matched with the patient category provided by the system; a plurality of responsible nurses can input shift information simultaneously through a plurality of computer hosts, the data system of the information boards of all ward areas in the computer hosts of the nurse station is automatically updated in real time, and the latest data is automatically updated by a single patient information board 15 minutes before the shift; before the shift, the shift nurse inputs shift content into a manual remarking area of a single patient information billboard according to the illness state of a patient and the actual nursing work requirement;
s2, when the nurse station centrally hands over, the nursing manager reasonably arranges human resources according to the information of the whole ward area, and the nurse taking over the work can display the detailed information of the patient corresponding to the icon by calling the intelligent shift report and logging in the information board of the whole ward area of the nurse station and clicking the icon, so that the distribution of the bed number and the state of the patient of the high-risk patient in the ward area can be known, the general situation of the whole ward area can be mastered, and the high-risk group can be identified;
s3, when the bedside one-to-one shift is carried out, the nurse transfers the patient data, the nursing evaluation and the important state comprehensively through the single patient information billboard at the mobile handheld PDA end, and simultaneously, the information in the remarking area of the single patient information billboard can be modified or recorded at any time according to the transfer condition.
The above is only a preferred embodiment of the present invention, and the protection scope of the present invention is not limited to the above embodiments, and all technical solutions belonging to the idea of the present invention belong to the protection scope of the present invention, it should be noted that, for those skilled in the art, several modifications and decorations without departing from the principle of the present invention should be regarded as the protection scope of the present invention.
Claims (9)
1. An intelligent nursing shift-switching system based on a clinical decision support system is characterized by comprising terminal equipment and a server, wherein the server is used for receiving patient data from each clinical information system, analyzing, integrating and comparing the patient data with knowledge of a knowledge base, and generating shift-switching information of a visual human-computer interaction end through an inference machine; the terminal equipment is used for inputting patient data and displaying shift information.
2. The clinical decision support system based intelligent nursing shift system according to claim 1, wherein the terminal device is connected to the server in wireless communication.
3. The clinical decision support system based intelligent nursing shift system according to claim 1, wherein the terminal devices comprise a nurse station computer PC terminal and a mobile handheld PDA.
4. An intelligent nursing shift-switching system based on clinical decision support system according to claim 1, characterized in that the shift-switching information comprises 3 presentation forms:
intelligent shift report of nurse station computer PC end: presenting shift information of patients in the ward in a table form;
nurse station computer PC end's full ward information billboard: the system is used for presenting critical information of the ward area concerned by the nursing visual angle;
single patient information billboard at mobile handheld PDA end: for presenting single patient key information during one-to-one shift, including basic information of the patient, care assessment, vital status information, and manual remark areas.
5. The clinical decision support system based intelligent care shift system according to claim 1, wherein the patient data comprises: basic information of the patient, including specifically the bed number, name, hospital number, sex, age, care level, diet, and major diagnosis; patient flow information, including in particular admission, discharge, death, diversion, surgery and delivery; the patient's vital signs data, including vital signs, symptom sign records and examination results; the main diagnosis and treatment records of the patient specifically comprise executive records of doctors and nurses.
6. The intelligent nursing shift-switching system based on clinical decision support system as claimed in claim 4, wherein the intelligent shift-switching report of the PC end of the nurse station presents the shift-switching information of the patients in the ward in a table form and provides the functions of editing, saving, deleting, referring and printing pages.
7. The intelligent nursing shift system based on clinical decision support system as claimed in claim 1, wherein the full ward information billboard at the PC of the nurse station is updated in real time, and has an upper part and a lower part, wherein the upper part displays a plurality of icons, and the lower part displays a plurality of icons, and the icons are assisted by the text, and the icons are displayed as icon + text + number of patients, and when the nurse clicks the icon on the upper part, the lower part can display the detailed information of the patient corresponding to the icon.
8. The intelligent nursing shift-work system based on clinical decision support system as claimed in claim 1, wherein the mobile handheld PDA-based single-patient information billboard comprises four information areas including patient basic data, nursing assessment, vital signs and manual remark areas; when the patient is in one-to-one shift at the bedside, the key information of the single patient is presented in four information areas, and the basic information, the nursing evaluation and the important state data of the patient are automatically collected, sorted, classified, filtered and presented by a system server according to the rules of a knowledge base.
9. An intelligent nursing shift-switching method based on a clinical decision support system is characterized by comprising the following steps:
s1, before the shift, a plurality of responsible nurses can input shift information through a plurality of computer hosts at the same time, the data system of the information board of the whole ward area in the computer hosts of the nurse station is automatically updated in real time, and the latest data is automatically updated by the information board of a single patient 15 minutes before the shift; before the shift, the shift nurse inputs shift content into a manual remarking area of a single patient information billboard according to the illness state of a patient and the actual nursing work requirement;
s2, when the nurse station centrally hands over, the nursing manager reasonably arranges human resources according to the information of the whole ward area, and the nurse taking over the work can display the detailed information of the patient corresponding to the icon by calling the intelligent shift report and logging in the information board of the whole ward area of the nurse station and clicking the icon, so that the distribution of the bed number and the state of the patient of the high-risk patient in the ward area can be known, the general situation of the whole ward area can be mastered, and the high-risk group can be identified;
s3, when the bedside one-to-one shift is carried out, the nurse transfers the patient data, the nursing evaluation and the important state comprehensively through the single patient information billboard at the mobile handheld PDA end, and simultaneously, the information in the remarking area of the single patient information billboard can be modified or recorded at any time according to the transfer condition.
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| CN111568543A (en) * | 2020-06-10 | 2020-08-25 | 浙江大学 | Doctor's operation handing-over checking system |
| CN112002384A (en) * | 2020-07-14 | 2020-11-27 | 金蝶医疗软件科技有限公司 | Method and device for summarizing medical record information, computer equipment and storage medium |
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| CN112599228A (en) * | 2020-12-16 | 2021-04-02 | 广州中智达信科技有限公司 | Intelligent shift switching method and system for medical institution |
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