| 摘要: |
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目的
对医院临床信息系统进行改造和完善，进行患者临床安全信息保障体系理论研究。方法 结合医院信息化实际，针对药品、护理、手术、检查、检验、输血六大类医嘱，分析其流转环节关键节点，进行信息闭环，研究护理执行文档、手术医疗器械以及消毒供应包管理追溯、医技报告危急值报警等信息标准化，建立数据集，实现病人临床安全的信息化支撑。结果 实现了护理文档数据标准化和移动护理数据采集的全面应用，探索了医嘱闭环信息的工程化建设方法，研发了移动护理软件，形成了护理工作绩效评价的新模式。结论 通过项目研究，在国内率先进行了护理文档标准化研究，形成了医嘱闭环执行与护士工作量评价新方法，并在患者临床安全的一系列关键环节进行了信息保障的全面应用。 |
| 关键词: 医嘱闭环 患者安全 移动护理 临床信息系统 |
| DOI： |
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| Research and Application of Patient Clinical Safety of Information Security System Based on Medical Orders Closed-loop Management |
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| Abstract: |
| Objective To improve and perfect the hospital clinical information system, and to make a theoretical study of the clinical safety of information security system of patients. Methods According to the actual situation of hospital information system, for medicine, nursing, operation, inspection, testing and blood transfusion, the key nodes of circulation were analyzed, the closed loop of information was done, the study focus of nursing implementation of document operation, disinfection of medical equipment and supply package management retrospection, medical report critical value alarm information standardization were researched, and data was established to realize the clinical safety of patients information support. Results The hospital clinical ward has achieved comprehensive application of nursing document data standardization and mobile nursing data acquisition, engineering construction method to study the prescribed closed-loop information, and research and development of mobile nursing software, and form a new mode of nursing performance evaluation. Conclusion Through project research, nursing documentation standards in China is firstly researched, a new method for evaluation of medical order closed loop execution and the workload of nurses is formed, and information in a series of key links of clinical safety of patients is comprehensively applied. |
| Key words: closed-loop medical order,patient safety,mobile nursing system,clinical information system |
