CN116864056A - Hospital nursing data processing method and platform - Google Patents

Hospital nursing data processing method and platform Download PDF

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Publication number
CN116864056A
CN116864056A CN202310652914.5A CN202310652914A CN116864056A CN 116864056 A CN116864056 A CN 116864056A CN 202310652914 A CN202310652914 A CN 202310652914A CN 116864056 A CN116864056 A CN 116864056A
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China
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unit
nursing
deep vein
patient
mobile terminal
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CN202310652914.5A
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孔繁昕
刘方
赵银萍
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State Grid Information and Telecommunication Co Ltd
Information and Telecommunication Branch of State Grid Beijing Electric Power Co Ltd
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State Grid Information and Telecommunication Co Ltd
Information and Telecommunication Branch of State Grid Beijing Electric Power Co Ltd
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Priority to CN202310652914.5A priority Critical patent/CN116864056A/en
Publication of CN116864056A publication Critical patent/CN116864056A/en
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    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
    • G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H40/00—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices
    • G16H40/20—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

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  • Health & Medical Sciences (AREA)
  • Engineering & Computer Science (AREA)
  • Epidemiology (AREA)
  • General Health & Medical Sciences (AREA)
  • Medical Informatics (AREA)
  • Primary Health Care (AREA)
  • Public Health (AREA)
  • Business, Economics & Management (AREA)
  • General Business, Economics & Management (AREA)
  • Biomedical Technology (AREA)
  • Measuring And Recording Apparatus For Diagnosis (AREA)

Abstract

The PC end nursing input template unit comprises a general nursing record template, a conventional patient critical nursing record template, an extracardiac patient critical nursing record template, a clinical indwelling deep vein catheter post-evaluation form template and an electrocardiographic monitoring record form template; the PC end deep vein catheterization management unit comprises a PC end deep vein catheterization management dictionary, a PC end deep vein catheterization management project name, a PC end deep vein catheterization management project primary option, a PC end deep vein catheterization management project secondary option and a body temperature measurement frequency configuration dictionary; the general nursing recording unit of the mobile terminal is used for recording general nursing contents of the patient at the mobile terminal; the critical care recording unit of the conventional patient is used for recording critical care content of the conventional patient; the extra-cardiac patient critical care recording unit is used for recording critical care content of the extra-cardiac patient. The application realizes the real-time query processing of nursing work data and provides basis for nursing staff to acquire timely and accurate information.

Description

Hospital nursing data processing method and platform
Technical Field
The application belongs to the technical field of medical information processing, and particularly relates to a hospital nursing data processing method and a platform.
Background
The nursing work is an important component part of the health care industry, and has important significance for promoting health construction and actively coping with population aging.
The traditional hospital HIS and EMR information resource system cannot meet the data management requirement of hospital nursing work, is inconvenient for inquiring and processing nursing work data in real time, and cannot realize timely processing and uploading of information by nursing staff at the bedside. In order to strengthen the informatization construction of nursing and adapt to the development of society, standardized management of nursing work data is necessary to be realized on the basis of the existing HIS and EMR information resources of hospitals.
Disclosure of Invention
Therefore, the application aims to provide a hospital nursing data processing method and platform so as to realize real-time query and processing of nursing work data and help nursing staff acquire timely and accurate information resources.
Based on the above object, the present application provides a hospital care data processing method configured with a PC end and a mobile end;
the PC end is provided with a basic application subsystem, the basic application subsystem comprises a nursing input template unit and a PC end deep vein catheterization management unit, and the nursing input template unit comprises a general nursing record template, a conventional patient critical nursing record template, an extracardiac patient critical nursing record template, a clinical indwelling deep vein catheter post-evaluation meter template and an electrocardiographic monitoring record single template; the PC end deep vein catheterization management unit comprises a PC end deep vein catheterization management dictionary, a PC end deep vein catheterization management project name, a PC end deep vein catheterization management project primary option, a PC end deep vein catheterization management project secondary option and a body temperature measurement frequency configuration dictionary;
The mobile terminal is provided with a general care recording unit, a conventional patient critical care recording unit and an extracardiac patient critical care recording unit; the general care recording unit is used for recording general care content of a patient at the mobile terminal, wherein the general care content comprises support for new increase, editing of the body temperature, pulse, respiration, blood pressure, blood sugar, mind, pipelines, wound dressing, skin condition and disease record of the patient; the critical care recording unit of the conventional patient is used for recording critical care content of the conventional patient, wherein the critical care content of the conventional patient comprises body temperature, pulse, respiration, blood pressure, blood sugar, blood oxygen saturation, pupil, oxygen inhalation, mind, pipeline, skin condition, input quantity, output quantity and illness state record; the critical care recording unit is used for recording critical care contents of the extra-cardiac patient, wherein the critical care contents of the extra-cardiac patient comprise body temperature, pulse, respiration, invasive blood pressure, noninvasive blood pressure, blood sugar, blood oxygen saturation, pupil oxygen inhalation, respiration mode, respirator model, cannula depth, set tidal volume, oxygen concentration, mind, pipeline, skin condition, body position, input quantity, output quantity and illness state record.
As a preferred scheme of the hospital care data processing method, the general care record template matches with a general care record template format used by a hospital; the conventional patient critical care record template matches a conventional patient critical care record template format used by a hospital; the extra-cardiac patient critical care recording template is matched with an extra-cardiac patient critical care recording template format used by a hospital;
the post-evaluation form of the clinical indwelling deep vein catheter is matched with the post-evaluation form of the clinical indwelling deep vein catheter of the hospital; and the electrocardiograph monitoring record single template is matched with the electrocardiograph monitoring record single template format of the hospital.
As a preferable scheme of the hospital care data processing method, the PC end deep vein catheterization management dictionary is provided with a deep vein catheterization editing limiting button; the PC end deep vein catheterization management project names are used for defining all filling project names of newly added catheterization, inspection maintenance and tube drawing operations in PC end deep vein catheterization management;
the primary options of the PC end deep vein catheterization management project are used for defining the primary options of 'single selection' and 'multiple selection' category projects of newly added catheterization, inspection maintenance and pulling operation in PC end deep vein catheterization management;
The secondary options of the PC end deep vein catheterization management project are used for defining secondary options of 'options' category projects of newly added catheterization, inspection maintenance and pulling operation in PC end deep vein catheterization management;
the body temperature measurement times configuration dictionary is used for setting daily measurement times of a body temperature bill.
As a preferred scheme of the hospital care data processing method, the PC end is further provided with a drug dictionary subsystem, the drug dictionary subsystem includes a drug dictionary unit, the drug dictionary unit is configured with a drug dictionary modification item, and the drug dictionary modification item is used for configuring a liquid volume and an osmotic pressure for the selected liquid drug.
As a preferred scheme of the hospital nursing data processing method, the PC end is further provided with an inpatient nurse workstation subsystem, the inpatient nurse workstation subsystem is provided with a dictionary of the correspondence between the disease areas and the nursing input function list, and the inpatient nurse workstation subsystem is further provided with a general nursing record sheet, a conventional patient critical nursing record sheet and an extracardiac patient critical nursing record sheet.
As a preferable scheme of the hospital nursing data processing method, the inpatient nurse workstation subsystem is further provided with a pressure sore risk assessment unit, wherein the pressure sore risk assessment unit comprises a pressure sore risk assessment item dictionary, a pressure sore risk assessment item result dictionary and a pressure sore risk assessment list;
The hospitalized nurse workstation subsystem is also provided with a fall risk assessment unit, and the fall risk assessment unit comprises a fall risk assessment item dictionary, a fall risk assessment item result dictionary and a fall risk assessment list;
the inpatient nurse workstation subsystem is also provided with a PC end life ability assessment unit, and the PC end life ability assessment unit comprises a daily life ability assessment item dictionary, a daily life ability assessment item result dictionary and a life ability assessment list.
As a preferable scheme of the hospital nursing data processing method, the inpatient nurse workstation subsystem is further provided with a PC end health ventilating and teaching unit, a PC end electrocardiograph monitoring and inputting unit, a PC end nursing and inputting unit, a PC end medical condition inquiring unit, a PC end nursing shift unit, a PC end injection medicine executing unit, a PC end specimen management unit, a PC end inpatient adult body temperature list unit, a PC end body temperature list inquiring and printing unit and a PC port medicine taking executing unit.
As a preferable scheme of the hospital nursing data processing method, the mobile terminal is provided with a mobile terminal life ability assessment unit, a mobile terminal health ventilating and teaching unit, a mobile terminal nursing recording unit, a mobile terminal electrocardiographic monitoring recording unit, a mobile terminal specimen acquisition unit, a mobile terminal inpatient adult body temperature bill unit, a mobile doctor advice unit, a mobile terminal oral medicine execution unit and a mobile terminal injection medicine execution unit.
As a preferable scheme of the hospital nursing data processing method, the mobile terminal is further provided with a mobile terminal deep vein catheterization management unit, and the mobile terminal deep vein catheterization management unit comprises a mobile terminal deep vein catheterization management item, a wristband sweeping item, a patrol maintenance item and a tube drawing item.
As a preferable scheme of the hospital nursing data processing method, the mobile terminal inpatient adult body temperature bill unit comprises a body temperature batch recording item, a body temperature single recording item and a cooling recording item.
The application also provides a hospital nursing data processing platform which is in butt joint with the hospital information management system and adopts the hospital nursing data processing method.
From the above, the technical scheme provided by the application is that a basic application subsystem is arranged at the PC end, the basic application subsystem comprises a nursing input template unit and a PC end deep vein catheterization management unit, and the nursing input template unit comprises a general nursing record template, a conventional patient critical nursing record template, an extracardiac patient critical nursing record template, a clinical indwelling deep vein catheter post-evaluation table template and an electrocardiographic monitoring record single template; the PC end deep vein catheterization management unit comprises a PC end deep vein catheterization management dictionary, a PC end deep vein catheterization management project name, a PC end deep vein catheterization management project primary option, a PC end deep vein catheterization management project secondary option and a body temperature measurement frequency configuration dictionary; the mobile terminal is provided with a general care recording unit, a conventional patient critical care recording unit and an extracardiac patient critical care recording unit; the general care recording unit is used for recording general care contents of the patient at the mobile terminal; the critical care recording unit of the conventional patient is used for recording critical care content of the conventional patient; the extra-cardiac patient critical care recording unit is used for recording critical care content of the extra-cardiac patient. The application realizes the real-time query and processing of nursing work data, provides a basis for nursing staff to acquire timely and accurate information resources, also provides support for nursing staff to timely process and upload information at the bedside, helps to optimize the flow of a hospital, improves the medical efficiency, and helps the hospital to realize the management concept of centering on patients.
Drawings
In order to more clearly illustrate the technical solutions of the present application or related art, the drawings that are required to be used in the description of the embodiments or related art will be briefly described below, and it is apparent that the drawings in the following description are only embodiments of the present application, and other drawings may be obtained according to the drawings without inventive effort to those of ordinary skill in the art.
Fig. 1 is a schematic diagram of a hospital care data processing method according to an embodiment of the present application.
Detailed Description
The present application will be further described in detail below with reference to specific embodiments and with reference to the accompanying drawings, in order to make the objects, technical solutions and advantages of the present application more apparent.
It should be noted that unless otherwise defined, technical or scientific terms used in the embodiments of the present application should be given the ordinary meaning as understood by one of ordinary skill in the art to which the present application belongs. The use of the terms "comprising" or "including" and the like in embodiments of the present application is intended to cover an element or article appearing before the term and equivalents thereof, which are listed after the term, without excluding other elements or articles.
Relevant documents indicate that the nursing informatization construction is enhanced by fully utilizing information technology such as cloud computing, big data, the Internet of things, block chains and the mobile Internet, combining with the development of the requirements of intelligent hospitals, the Internet, medical health and the like. By utilizing an informatization means, a nursing service mode is innovated, and convenient and efficient nursing service is provided for patients. The nursing service flow is optimized, the clinical nursing work efficiency is improved, and unnecessary workload of nurses is reduced. The nursing management system based on problems and requirements is established as a guide, and has the functions of manual allocation, post training, performance assessment, quality improvement, subject construction and the like of nurses, so that modernization, scientization and refinement of nursing management are gradually realized.
In the traditional technology, the related hospital information system has long running time, is not supported by a system developer, cannot adapt to the enhanced nursing informatization construction required by related files, and combines and develops the requirements of intelligent hospitals, the Internet, medical health and the like in order to fully use the informatization technologies such as cloud computing, big data, the Internet of things, blockchain, mobile Internet and the like.
In view of the above, the invention provides a hospital nursing data processing method, which takes a clinical nursing information system as a background, seamlessly interfaces the existing HIS and EMR information resources of a hospital, acquires and reutilizes the progressive data, realizes the real-time query and processing of nursing work data, provides a basis for nursing staff to acquire timely and accurate information resources, also provides support for nursing staff to timely process and upload information at the bedside, helps the hospital to optimize the flow, improves the medical efficiency, and helps the hospital to realize the management concept of centering on patients.
Referring to fig. 1, an embodiment of the present invention provides a hospital care data processing method configured with a PC end and a mobile end;
the PC end is provided with a basic application subsystem, the basic application subsystem comprises a nursing input template unit and a PC end deep vein catheterization management unit, and the nursing input template unit comprises a general nursing record template, a conventional patient critical nursing record template, an extracardiac patient critical nursing record template, a clinical indwelling deep vein catheter post-evaluation meter template and an electrocardiographic monitoring record single template; the PC end deep vein catheterization management unit comprises a PC end deep vein catheterization management dictionary, a PC end deep vein catheterization management project name, a PC end deep vein catheterization management project primary option, a PC end deep vein catheterization management project secondary option and a body temperature measurement frequency configuration dictionary;
the mobile terminal is provided with a general care recording unit, a conventional patient critical care recording unit and an extracardiac patient critical care recording unit; the general care recording unit is used for recording general care content of a patient at the mobile terminal, wherein the general care content comprises support for new increase, editing of the body temperature, pulse, respiration, blood pressure, blood sugar, mind, pipelines, wound dressing, skin condition and disease record of the patient; the critical care recording unit of the conventional patient is used for recording critical care content of the conventional patient, wherein the critical care content of the conventional patient comprises body temperature, pulse, respiration, blood pressure, blood sugar, blood oxygen saturation, pupil, oxygen inhalation, mind, pipeline, skin condition, input quantity, output quantity and illness state record; the critical care recording unit is used for recording critical care contents of the extra-cardiac patient, wherein the critical care contents of the extra-cardiac patient comprise body temperature, pulse, respiration, invasive blood pressure, noninvasive blood pressure, blood sugar, blood oxygen saturation, pupil oxygen inhalation, respiration mode, respirator model, cannula depth, set tidal volume, oxygen concentration, mind, pipeline, skin condition, body position, input quantity, output quantity and illness state record.
In this embodiment, the general care record template matches a general care record template format used by a hospital; the conventional patient critical care record template matches a conventional patient critical care record template format used by a hospital; the extra-cardiac patient critical care record template matches an extra-cardiac patient critical care record template format used by a hospital. The general care record template, the conventional patient critical care record template and the extra-cardiac patient critical care record template can be newly added and edited, and the list fields comprise applicable classifications, template names, template contents, input codes, application ranges, states, final storage time, final storage people, drafting time and drafting people.
In this embodiment, the post-clinical indwelling deep venous catheter assessment table template matches a post-clinical indwelling deep venous catheter assessment table format of a hospital; and the electrocardiograph monitoring record single template is matched with the electrocardiograph monitoring record single template format of the hospital. According to the clinical deep vein catheter post-evaluation form of indwelling in a hospital, a clinical deep vein catheter post-evaluation form is set, and according to the electrocardiograph monitoring record form of a hospital, an electrocardiograph monitoring record form is set, wherein the clinical deep vein catheter post-evaluation form and the electrocardiograph monitoring record form can be newly added and edited, and list fields comprise applicable classification, template name, template content, input code, application range, state, final storage time, final storage person, drafting time and drafting person.
In this embodiment, the PC-side deep vein catheterization management dictionary is configured with a deep vein catheterization editing limit button; the PC end deep vein catheterization management project names are used for defining all filling project names of newly added catheterization, inspection maintenance and tube drawing operations in PC end deep vein catheterization management; the primary options of the PC end deep vein catheterization management project are used for defining the primary options of 'single selection' and 'multiple selection' category projects of newly added catheterization, inspection maintenance and pulling operation in PC end deep vein catheterization management; the secondary options of the PC end deep vein catheterization management project are used for defining secondary options of 'options' category projects of newly added catheterization, inspection maintenance and pulling operation in PC end deep vein catheterization management.
The deep vein catheterization limiting button realizes deep vein catheterization limiting parameters, and when the deep vein catheterization limiting button is closed, all catheterization records can be edited; when open, editing is only allowed for "in-the-middle" recordings of hospital patients. The name of the PC end deep vein catheterization management item is used for defining all filling item names of newly added catheterization, inspection maintenance and catheterization operations in deep vein catheterization management, and the filling item names comprise classification, item names, sorting, category, data type, nursing input list items, query conditions, query list items, printing and state. The list is arranged in a sorting order.
The PC end deep vein catheterization management project first-level options comprise one-level options of 'single-selection' and 'multi-selection' category projects for defining new catheterization, inspection maintenance and catheterization operation in deep vein catheterization management, and the first-level options comprise classification, project names, one-level options, sequencing and states. The list is arranged in the order of classification, item ordering, and first level option ordering. The PC end deep vein catheterization management project secondary option is used for defining a secondary option of an option category project of newly added catheterization, inspection maintenance and pulling operation in deep vein catheterization management, and comprises classification, project name, primary option, secondary option, sequencing, infection early warning and state. The list is arranged in a sorting, item ordering, primary option ordering, secondary option ordering order.
The body temperature measurement times configuration dictionary is used for setting daily measurement times of a body temperature sheet. The daily measurement times of the body temperature list can be set by newly creating a body temperature measurement times configuration dictionary, and new measurement times rules are added by selecting the body temperature measurement times, filling in priorities, measuring conditions according to the frequency and the like.
In this embodiment, the basic application subsystem further includes a care input dictionary, and the addition dictionary interface is opened, so that new care input items can be added by selecting item categories, filling item codes, primary items, and the like. The basic application subsystem further comprises a nursing shift dictionary, wherein the nursing shift dictionary comprises an order item, a medical order dictionary, a nursing diagnosis dictionary and an order group, the order item dictionary for nursing shift is built, a nurse can conveniently and directly call the order item during shift, the medical order dictionary for nursing shift is built, the nurse can conveniently and directly call the order dictionary during shift, the nursing diagnosis dictionary for nursing shift is built, the nurse can conveniently and directly call the nursing diagnosis dictionary during shift, the order group for nursing shift is built, and the nurse can conveniently and directly call the order item during shift.
In this embodiment, the basic application subsystem further includes an order item dictionary and a check order, and in order to accurately define the multiple specimen order acquisition time interval, in order item cost and check, the "check" tab page increases the "acquisition time interval (minutes)". The "project group" field is added to the exam order at the base application subsystem.
In this embodiment, the PC end is further provided with a drug dictionary subsystem, where the drug dictionary subsystem includes a drug dictionary unit, and the drug dictionary unit is configured with a drug dictionary modification item, and the drug dictionary modification item is used to configure a liquid amount and an osmotic pressure for the selected liquid drug.
In this embodiment, the PC end still is equipped with the nurse workstation subsystem that inputes, the nurse workstation subsystem that inputes is equipped with the ward and the function list corresponds relation dictionary is typeeed with the nursing, the nurse workstation subsystem that inputes still is equipped with general nursing record list, conventional patient critical care record list, extracardiac patient critical care record list.
The general care record sheet is used for nurses to record general care contents of patients in daily life, including body temperature, pulse, respiration, blood pressure, blood sugar, mind, pipelines, wound dressing, skin condition, illness state record and the like, and can support calling template input. The general care record list is also used for nurses to record general care content of single patients in daily life, including body temperature, pulse, respiration, blood pressure, blood sugar, mind, pipelines, wound dressing, skin condition, illness record and the like, can support calling template input, and supports printing of single patients. The general nursing record list is used for switching, and displays general nursing record switching list of all patients in the disease area, including information of the patients in the disease area, such as temperature, blood pressure, respiration, pulse, blood sugar and the like.
The normal patient critical care record list comprises a critical (critical) care record list, a single patient critical (critical) care record and a critical (critical) care record handover list, wherein the critical (critical) care record list is used for recording the care content of all critical (critical) patients, including body temperature, pulse, respiration, blood pressure, blood sugar, blood oxygen saturation, pupils, oxygen inhalation, mind, pipelines, skin conditions, input quantity, output quantity, disease records and the like. Support new addition, editing, template invocation. The single patient critical (critical) care records are used for recording critical (critical) contents of single patient critical (critical) patients, including body temperature, pulse, respiration, blood pressure, blood sugar, blood oxygen saturation, pupil, oxygen inhalation, mind, pipeline, skin condition, input quantity, output quantity, disease record and the like, supporting the addition, editing and template calling, and supporting the critical (critical) record printing of single patient. The critical (severe) nursing record delivery list is used for delivery of all critical (severe) patients in the disease area, and statistics including body temperature, pulse, respiration, blood pressure, blood sugar, blood oxygen saturation, pupil, oxygen inhalation, mind, pipeline, skin condition, input quantity, output quantity, disease record and the like are performed according to the ascending sequence of bed numbers and date and time.
The extra-cardiac patient critical care record comprises an extra-cardiac patient critical care record, an extra-cardiac single patient critical care record and an extra-cardiac patient critical care record handover list; the critical care record sheet for the extra-cardiac patient is used for recording critical care contents of the extra-cardiac patient, including body temperature, pulse, respiration, blood pressure (invasive), blood pressure (noninvasive), blood sugar, blood oxygen saturation, pupil, oxygen inhalation, respiration mode, model of a respirator, cannula depth, set tidal volume, oxygen concentration, mind, pipeline, skin condition, body position, input quantity, output quantity, condition record and the like. The critical care record list of the single extracardiac patient is used for recording critical care contents of the single extracardiac patient, including body temperature, pulse, respiration, blood pressure (invasive), blood pressure (noninvasive), blood sugar, blood oxygen saturation, pupil, oxygen inhalation, respiration mode, model of a respirator, cannula depth, set tidal volume, oxygen concentration, mind, pipeline, skin condition, body position, input volume, output volume, condition record and the like. The extra-cardiac patient critical care record list is used for a shift, and comprises care records of all critical patients in the disease area, and statistics are carried out according to the bed number and the time-of-day ascending sequence.
In this embodiment, the inpatient nurse workstation subsystem is further provided with a pressure sore risk assessment unit, and the pressure sore risk assessment unit includes a pressure sore risk assessment item dictionary, a pressure sore risk assessment item result dictionary, and a pressure sore risk assessment list.
The pressure sore risk assessment item dictionary is used for defining pressure sore risk, the pressure sore risk assessment item result dictionary is used for judging pressure sore risk assessment results of patients, and pressure sore risk assessment is carried out on the patients on the basis of definition of the pressure sore risk assessment item and the pressure sore risk assessment item result, assessment scores are obtained, and a pressure sore risk assessment table is formed.
In this embodiment, the inpatient nurse workstation subsystem is further provided with a fall risk assessment unit, and the fall risk assessment unit includes a fall risk assessment item dictionary, a fall risk assessment item result dictionary, and a fall risk assessment list.
The fall risk assessment unit is used for defining fall risk items of patients, and the fall risk item result dictionary is used for judging fall risk item results of the patients. And carrying out the fall risk assessment on the patient on the basis of the definition of the fall risk assessment item and the fall risk assessment item result, and obtaining the assessment score to form a fall risk assessment list.
In this embodiment, the inpatient nurse workstation subsystem is further provided with a PC-side living ability assessment unit, and the PC-side living ability assessment unit includes a daily living ability assessment item dictionary, a daily living ability assessment item result dictionary, and a living ability assessment list.
The daily life ability assessment item dictionary is used for defining the assessment of the daily life ability of the patient, and the daily life ability assessment item result dictionary is used for assessing the daily life ability assessment item result. Based on the definition of the daily life ability assessment item and the daily life ability assessment item result, the patient is subjected to the hospital admission life ability assessment and the hospital discharge life ability assessment, and an assessment score is obtained and recorded on the first page of the medical records.
In this embodiment, the inpatient nurse workstation subsystem is still equipped with PC end health propaganda unit, PC end electrocardiograph guardianship input unit, PC end nursing input unit, PC end medical conditions inquiry unit, PC end nursing shift unit, PC end injection medicine execution unit, PC end sample management unit, PC end inpatient adult body temperature list unit, PC end body temperature list inquiry print unit and PC port execution unit of taking medicine.
The PC end health ventilating and teaching unit comprises a health ventilating and teaching project dictionary and a health ventilating and teaching list, wherein the health ventilating and teaching project dictionary is used for defining contents of safety problems, precautionary measures and special nursing health education. The health ventilating and teaching list is used for informing the patient or family members of the contents such as safety problems, precautionary measures, special nursing health education, and the like, and supports new addition, editing, printing, and the like of nurses.
The PC end electrocardiograph monitoring and recording unit comprises an electrocardiograph monitoring record sheet, an electrocardiograph monitoring record sheet of a single patient and an electrocardiograph monitoring record handover sheet, wherein the electrocardiograph monitoring record sheet is used for recording electrocardiograph monitoring contents of the patient, including blood pressure (noninvasive), blood pressure (invasive), heart rate, respiration, blood oxygen, central venous pressure, illness state record and the like. The single-patient electrocardiograph monitoring record sheet is used for recording electrocardiograph monitoring contents of a single patient, including blood pressure (noninvasive), blood pressure (invasive), heart rate, respiration, blood oxygen, central venous pressure, illness state record and the like, and supports the single patient. The electrocardiographic monitoring record transfer list comprises blood pressure (noninvasive), blood pressure (invasive), heart rate, respiration, blood oxygen, central venous pressure, illness state record and the like of all electrocardiographic monitoring patients in the illness region, and supports the addition, batch input, editing, deletion and printing.
The PC end nursing input unit comprises deep vein catheterization management, inspection maintenance and catheterization, wherein the middle part of a deep vein catheterization management page displays all catheterization records of the patient in the hospital at this time, and the catheterization records are arranged in a reverse order according to new time of the records; and displaying the item marked as yes in the nursing input list item in the newly added item according to the deep vein catheterization dictionary, the catheterization state, infection early warning, the last save time and the last save person. Opening a patrol maintenance bullet frame; and displaying an input box or options according to the category, wherein the options are displayed according to the first-level options and the second-level options of the items. Selecting one record, clicking a tube drawing, opening a tube drawing spring frame, displaying an input frame or options according to the category, and displaying the options according to the first-level options and the second-level options of the item.
The PC end medical condition query unit can count the patient information, the tube setting information, the inspection maintenance information and the tube drawing information of the deep vein tube according to the conditions of a department, a hospital number, a hospital time, a state, infection, early warning statistics and the like.
The PC end nursing shift-changing unit comprises nursing diagnosis, long-term nursing diagnosis, nursing diagnosis stop, temporary nursing diagnosis, nursing diagnosis DC, electronic medical record display and appointment time input; hospitalized patients have specific care diagnoses on the day of treatment, on the day of examination, before surgery, after surgery, etc. Nurses use the care diagnostic function to give care diagnosis to patients. And a long-term care diagnosis interface for displaying the long-term care content of the patient. The nurse opens the page of long-term nursing diagnosis, which is convenient for the nurse to open long-term nursing diagnosis for patients and supports copy nursing diagnosis. After the nurse carries out long-term nursing diagnosis for the patient, the system provides the function of hearing the nursing diagnosis, and is convenient for the nurse to stop long-term nursing for the patient. And a short-term care diagnosis interface for displaying short-term care content of the patient. The nurse opens the page of the temporary nursing diagnosis, which is convenient for the nurse to develop the temporary nursing diagnosis for the patient and supports the duplication nursing diagnosis. After the nurse develops a short-term care diagnosis for the patient, the system supports care diagnosis DC, facilitating the nurse to stop short-term care diagnosis for the patient. And supporting to quickly open an interface of the electronic medical record at a nursing shift interface, and displaying the electronic medical record of the patient at a nurse station. And a reservation time input function is provided on a nurse shift interface, so that the nurses are supported to record the time of reservation items which need to be recorded, and the shift of the nurses is facilitated.
The PC side injection medicine execution unit generates an injection medicine bar code with a patient two-dimension code according to an order execution node of an order, an order execution node time interval, a medicine prompt node and a medicine order execution prompt. The function of the mobile terminal is used for performing management on the injection medicines of the inpatients according to a closed-loop flow.
The PC end specimen management unit comprises a test specimen, a specimen group bar code printing, a scanning code entering group and a specimen rollback. The specimen management page enables a nurse to change the specimen sampling time. If the default sampling time is used, the print button can be directly clicked to print the label, if the sampling time is changed by filling in, the point is saved, and then the print label is clicked. The sample group bar code printing page, the collection date defaults to display the same day, clicks the 'last day', the collection date switches to the last day, clicks the 'last day', the collection date switches to the same day, and bar code printing is carried out according to the set sample group. The sample group code and the sample code can be scanned in sequence to realize sample group entering, the code scanning is performed on a list on the right side of a group page, the sample group entering page comprises a serial number, a standard number, a project, a sample remark and collected samples, the samples are displayed according to the sequence of the sample numbers, and the samples (the samples which contain the group entering and are invalid as yes or not) of the sampling time are displayed. The sample after the code scanning can be carried out with the sample rollback operation, and the code is re-coded to collect the sample after the sample rollback operation.
The PC-end inpatient adult body temperature bill unit establishes an adult body temperature bill according to the latest body temperature bill template, and comprises body temperature batch input, body temperature single input, input and output batch input, input and output single input, input liquid amount change, cycle and printing. And the temperature list is synchronously adjusted and updated in the functions of inpatient orders, inpatient data (medical records room) and the like. The PC end body temperature bill inquiry printing unit can open a single body temperature input interface and can input relevant items of the body temperature of the patient.
The PC port medicine taking execution unit generates an oral medicine bar code with a patient two-dimension code according to an order execution node of an order, an order execution node time interval, a medicine prompt node and a medicine order execution prompt. The functions of the barcode printing and the mobile terminal can be used for executing management on oral medicines of inpatients according to a closed-loop process.
In this embodiment, the mobile terminal is configured with a mobile terminal living ability assessment unit, a mobile terminal health ventilating and teaching unit, a mobile terminal nursing recording unit, a mobile terminal electrocardiographic monitoring recording unit, a mobile terminal specimen collection unit, a mobile terminal inpatient adult body temperature bill unit, a mobile doctor advice unit, a mobile terminal oral medicine execution unit and a mobile terminal injection medicine execution unit.
The mobile terminal life ability assessment unit is used for carrying out hospital admission life ability assessment and hospital discharge life ability assessment on the patient, obtaining assessment scores, recording the assessment scores on a first page of a medical record, and supporting the new adding and editing operation of the mobile terminal. The mobile terminal health ventilating and teaching unit is used for informing the contents such as 'safety problem', 'precautionary measure', 'special nursing health education' and the like of a patient or family, and supporting the new adding and editing operation of the mobile terminal.
In the nursing recording unit of the mobile terminal, in the recording function of nursing recording of the nursing mobile terminal, a recording sheet is opened, and after the patient wrist strap is scanned, a nurse can record the patient's recording information at the first time of patient bedside and the like. In the discharge recording function of nursing recording of nursing mobile terminal, open and record the list, after scanning patient wrist strap, nurse can be at patient bedside etc. the discharge information of patient of first time recording. In the blood sugar function of nursing record of nursing mobile terminal, open the record list, after scanning patient wrist strap, nurse can be at patient bedside etc. the blood sugar information of patient of first time record. And (3) at the nursing mobile terminal, a nursing record opening function of nursing record is used for scanning the wrist strap of the patient, and after the patient is selected, the nursing record of the patient is recorded.
The mobile end electrocardiograph monitoring and recording unit is used for recording electrocardiograph monitoring contents of a patient, including blood pressure (noninvasive), blood pressure (invasive), heart rate, respiration, blood oxygen, central venous pressure, illness state recording and the like. And supporting the operations of the new addition, batch recording, editing and mobile terminal.
The mobile terminal also supports scanning the patient wrist strap, enters a nursing record list page, and adds deep vein catheterization management in the list. The tube record list field comprises a tube name, tube time, infection and early warning and state.
The mobile terminal specimen collection unit clicks a specimen button in a mobile nursing main page, a specimen scanning/specimen group bar code is opened to scan a specimen bar code, a scanning wrist strap is opened to scan a wrist strap, the specimen state is judged, a check is clicked, and if the specimen is multiple specimens, the preset sampling time of all specimens of the medical advice is updated according to the actual sampling time and the sampling interval.
After the mobile terminal logs in, the patient area is selected, a body temperature (batch) button is clicked, and a body temperature batch recording interface is opened. The body temperature, pulse, heart rate, respiration, blood pressure and the like Shan Xiangmu of the patient are input in batches (input items, a nursing input dictionary is displayed for inputting an acquisition mode, an inpatient ward contains a current ward, and a body temperature list item of an enabling state (namely, an item type is a body temperature list)) is displayed according to the selected body temperature measurement times. The entry item may scroll longitudinally/laterally.
Wherein, in the adult body temperature list unit of mobile terminal inpatient, click and type in (single) button, open and type in (single) interface. After the wristband is scanned, a single body temperature entry page for the patient is opened. The date is selected (default display day), the body temperature, pulse, heart rate, respiration, blood pressure and the like Shan Xiangmu of the patient just scanning the wristband are recorded (the recording item, the display nursing recording dictionary "acquisition mode" is recorded, "hospitalization ward" contains the current ward, and the body temperature list item in the starting state (namely, "item category" is body temperature list)). Clicking the away button may select the reason for the away.
Wherein, in the adult body temperature list unit of mobile terminal inpatient, click and type in (single) button, open and type in (single) interface. After the wrist strap is scanned, the patient cooling entry page is opened. A single cooling entry page, the first patient of the default patient list, the patient cooling temperature just scanning the wristband.
And clicking an in-out quantity (batch) button in the adult body temperature bill unit in the mobile terminal, and opening an in-out quantity batch input interface. The input quantity items such as patient input quantity, urine quantity, vomiting and the like can be input in batches by selecting a date (default display day) (input items, display nursing input dictionary ' acquisition mode ' is input, a ' inpatient ward ' contains a current ward, and input quantity items in an enabling state (namely ' item category ' is input quantity)), so that a doctor is required to have an input quantity doctor's advice corresponding to the input quantity. The entry item may scroll longitudinally/laterally.
Wherein, in the adult body temperature list unit of mobile terminal inpatient, click and type in (single) button, open and type in (single) interface. After the wristband is scanned, a single access quantity entry page for the patient is opened. Entry and exit items of patient entrance amount, urine amount, vomiting and the like of the wristband just scanned are entered (entry item, display nursing entry dictionary "acquisition mode" is entered, "inpatient ward" contains current ward, and entry and exit item of enabling state (namely, "item category" is entry and exit amount)). The entry item may scroll longitudinally.
Wherein, in the adult body temperature list unit of mobile terminal inpatient, click and type in (single) button, open and type in (single) interface. Clicking the 'change liquid input amount', and opening the prompt of the wrist strap. The liquid input interface is opened, and the current day liquid input and the next day liquid input items of the patient who just swiped the wristband can be entered by selecting the date (the day of default display). The bleeding items are displayed according to the bleeding list, namely, the items from the selected date 7:00 (containing the blood) to the next date 7:00, the blood products are all hypertonic, and the medicine osmotic pressure is determined according to the medicine dictionary.
The mobile doctor's advice unit is used for resident nurses to inquire at the mobile terminal doctor's advice, patient information inquire, doctor's advice inquiry, history doctor's advice inquiry, long-term doctor's advice stops daily execution record etc.
In the mobile terminal oral medicine execution unit, a nurse opens the mobile terminal oral medicine execution before issuing oral medicine to a patient, opens a checking interface, scans codes, checks medicine states, stores the last checking person and checking time medicine states after checking is completed as checking, has unusable orders, does not allow checking to be completed, and can take out disabled or unusable orders. Before the nurse dispenses oral medicine to the patient, the nurse opens the mobile terminal oral medicine and executes, opens the medicine dispensing interface, sweeps the code, sweeps the patient wrist strap, automatically checks patient information, medicine information and doctor's advice state, and medicine in the medicine checking completion state can be dispensed.
In the mobile end injection medicine execution unit, after medicine placement of injection medicines for patients is completed, a nurse scans medicine codes for automatic check, checks doctor's advice state, checks medicine state correctly, stores last check person and check time, checks medicine state as check, and cannot perform check operation when checking that medicine information is incorrect. After the injection medicine of a patient is checked, when medicine is prepared, a medicine code is scanned, automatic check is carried out, doctor's advice state, medicine state and check state are checked, medicine in the check completion state can be prepared, the liquid preparation operation can be completed, the liquid preparation person and the liquid preparation time are saved, and the medicine state is prepared. After the preparation of the liquid is completed, a nurse checks patient information through sweeping a medicine code and a patient wrist strap, and the patient is in a hospital: judging whether the hospitalization numbers of the medicines and the wrist bands are consistent; leaving the patient in view: judging whether the clinic number/manual number of the medicine and the wrist strap are consistent, checking whether the medicine arranging, checking and liquid preparing processes are finished, and injecting after the above states are finished. Preserving the injection person and the injection time, and the medicine state is injection.
In summary, according to the technical scheme provided by the application, the PC end is provided with the basic application subsystem, the basic application subsystem comprises a nursing input template unit and a PC end deep vein catheterization management unit, and the nursing input template unit comprises a general nursing record template, a conventional patient critical nursing record template, an extracardiac patient critical nursing record template, a clinical indwelling deep vein catheter post-evaluation meter template and an electrocardiographic monitoring record single template; the PC end deep vein catheterization management unit comprises a PC end deep vein catheterization management dictionary, a PC end deep vein catheterization management project name, a PC end deep vein catheterization management project primary option, a PC end deep vein catheterization management project secondary option and a body temperature measurement frequency configuration dictionary; the mobile terminal is provided with a general care recording unit, a conventional patient critical care recording unit and an extracardiac patient critical care recording unit; the general care recording unit is used for recording general care contents of the patient at the mobile terminal; the critical care recording unit of the conventional patient is used for recording critical care content of the conventional patient; the extra-cardiac patient critical care recording unit is used for recording critical care content of the extra-cardiac patient. The hospitalized nurse workstation subsystem is also provided with a pressure sore risk assessment unit, and the pressure sore risk assessment unit comprises a pressure sore risk assessment item dictionary, a pressure sore risk assessment item result dictionary and a pressure sore risk assessment list; the inpatient nurse workstation subsystem is also provided with a fall risk assessment unit, and the fall risk assessment unit comprises a fall risk assessment item dictionary, a fall risk assessment item result dictionary and a fall risk assessment list; the inpatient nurse workstation subsystem is also provided with a PC-end life ability assessment unit, and the PC-end life ability assessment unit comprises a daily life ability assessment item dictionary, a daily life ability assessment item result dictionary and a life ability assessment list. The inpatient nurse workstation subsystem is also provided with a PC end health ventilating and teaching unit, a PC end electrocardiograph monitoring and inputting unit, a PC end nursing and inputting unit, a PC end medical condition inquiring unit, a PC end nursing shift unit, a PC end injection medicine executing unit, a PC end specimen management unit, a PC end inpatient adult body temperature bill unit, a PC end body temperature bill inquiring and printing unit and a PC end medicine taking executing unit. The mobile terminal is provided with a mobile terminal life ability assessment unit, a mobile terminal health ventilating and teaching unit, a mobile terminal nursing recording unit, a mobile terminal electrocardiograph monitoring recording unit, a mobile terminal specimen acquisition unit, a mobile terminal inpatient adult body temperature bill unit, a mobile doctor advice unit, a mobile terminal oral medicine execution unit and a mobile terminal injection medicine execution unit. The application realizes the real-time query and processing of nursing work data, provides a basis for nursing staff to acquire timely and accurate information resources, also provides support for nursing staff to timely process and upload information at the bedside, helps to optimize the flow of a hospital, improves the medical efficiency, and helps the hospital to realize the management concept of centering on patients.
On the basis of the embodiment, a hospital care data processing platform is also provided, which is in butt joint with the hospital information management system, and the hospital care data processing method of the embodiment is adopted.
The present embodiments are intended to embrace all such alternatives, modifications and variances which fall within the broad scope of the appended claims. Therefore, any omissions, modifications, equivalent substitutions, improvements, and the like, which are within the spirit and principles of the embodiments of the application, are intended to be included within the scope of the application.

Claims (10)

1. A hospital nursing data processing method, which is characterized in that a PC end and a mobile end are configured;
the PC end is provided with a basic application subsystem, the basic application subsystem comprises a nursing input template unit and a PC end deep vein catheterization management unit, and the nursing input template unit comprises a general nursing record template, a conventional patient critical nursing record template, an extracardiac patient critical nursing record template, a clinical indwelling deep vein catheter post-evaluation meter template and an electrocardiographic monitoring record single template; the PC end deep vein catheterization management unit comprises a PC end deep vein catheterization management dictionary, a PC end deep vein catheterization management project name, a PC end deep vein catheterization management project primary option, a PC end deep vein catheterization management project secondary option and a body temperature measurement frequency configuration dictionary;
The mobile terminal is provided with a general care recording unit, a conventional patient critical care recording unit and an extracardiac patient critical care recording unit; the general care recording unit is used for recording general care content of a patient at the mobile terminal; the critical care recording unit of the conventional patient is used for recording critical care content of the conventional patient; the critical care recording unit of the extracardiac patient is used for recording critical care content of the extracardiac patient.
2. A method of hospital care data processing according to claim 1, wherein the general care record template matches a general care record template format used by a hospital; the conventional patient critical care record template matches a conventional patient critical care record template format used by a hospital; the extra-cardiac patient critical care recording template is matched with an extra-cardiac patient critical care recording template format used by a hospital;
the post-evaluation form of the clinical indwelling deep vein catheter is matched with the post-evaluation form of the clinical indwelling deep vein catheter of the hospital; and the electrocardiograph monitoring record single template is matched with the electrocardiograph monitoring record single template format of the hospital.
3. The hospital care data processing method according to claim 1, wherein the PC-side deep vein catheterization management dictionary is configured with a deep vein catheterization edit limit button; the PC end deep vein catheterization management project names are used for defining all filling project names of newly added catheterization, inspection maintenance and tube drawing operations in PC end deep vein catheterization management;
The primary options of the PC end deep vein catheterization management project are used for defining the primary options of 'single selection' and 'multiple selection' category projects of newly added catheterization, inspection maintenance and pulling operation in PC end deep vein catheterization management;
the secondary options of the PC end deep vein catheterization management project are used for defining secondary options of 'options' category projects of newly added catheterization, inspection maintenance and pulling operation in PC end deep vein catheterization management;
the body temperature measurement times configuration dictionary is used for setting daily measurement times of a body temperature bill.
4. The hospital care data processing method according to claim 1, wherein the PC side is further provided with a drug dictionary subsystem including a drug dictionary unit configured with drug dictionary modification items for configuring a liquid amount and an osmotic pressure for the selected liquid drug.
5. The hospital nursing data processing method according to claim 1, wherein the PC end is further provided with a inpatient nurse workstation subsystem, the inpatient nurse workstation subsystem is provided with a dictionary of correspondence between the disease areas and the nursing input function list, and the inpatient nurse workstation subsystem is further provided with a general nursing record sheet, a conventional patient critical nursing record sheet and an extracardiac patient critical nursing record sheet.
6. The hospital care data processing method according to claim 5, wherein the inpatient nurse workstation subsystem is further provided with a pressure sore risk assessment unit, and the pressure sore risk assessment unit comprises a pressure sore risk assessment item dictionary, a pressure sore risk assessment item result dictionary and a pressure sore risk assessment list;
the hospitalized nurse workstation subsystem is also provided with a fall risk assessment unit, and the fall risk assessment unit comprises a fall risk assessment item dictionary, a fall risk assessment item result dictionary and a fall risk assessment list;
the inpatient nurse workstation subsystem is also provided with a PC end life ability assessment unit, and the PC end life ability assessment unit comprises a daily life ability assessment item dictionary, a daily life ability assessment item result dictionary and a life ability assessment list.
7. The hospital nursing data processing method according to claim 6, wherein the inpatient nurse workstation subsystem is further provided with a PC end health ventilating and teaching unit, a PC end electrocardiographic monitoring and inputting unit, a PC end nursing and inputting unit, a PC end medical condition inquiring unit, a PC end nursing shift-changing unit, a PC end injection medicine executing unit, a PC end specimen managing unit, a PC end inpatient adult body temperature list unit, a PC end body temperature list inquiring and printing unit and a PC port medicine taking executing unit.
8. The hospital care data processing method according to claim 1, wherein the mobile terminal is configured with a mobile terminal living ability assessment unit, a mobile terminal health ventilating unit, a mobile terminal care recording unit, a mobile terminal electrocardiograph monitoring recording unit, a mobile terminal specimen collection unit, a mobile terminal inpatient adult body temperature bill unit, a mobile doctor advice unit, a mobile terminal oral medicine execution unit and a mobile terminal injection medicine execution unit.
9. The hospital care data processing method according to claim 8, wherein the mobile terminal is further configured with a mobile terminal deep vein catheterization management unit, and the mobile terminal deep vein catheterization management unit includes a mobile terminal deep vein catheterization management item, a wristband item, a patrol maintenance item, and a tube drawing item;
the mobile terminal inpatient adult body temperature list unit comprises a body temperature batch recording item, a body temperature single recording item and a cooling recording item.
10. A hospital care data processing platform interfacing with a hospital information management system, characterized in that the hospital care data processing method of any of claims 1 to 9 is employed.
CN202310652914.5A 2023-06-02 2023-06-02 Hospital nursing data processing method and platform Pending CN116864056A (en)

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