Hao Angelica Te-Hui, Hsu Chien-Yeh, Li-Fang Huang, Jian Wen-Shan, Wu Li-Bin, Kao Ching-Chiu, Lu Mei-Show, Chang Her-Kung
Information Management Division, Department of Business Administration, Chang Gung University.
Stud Health Technol Inform. 2006;124:313-9.
The nursing process consists of five interrelated steps: assessment, diagnosis, planning, intervention, and evaluation. In the nursing process, the nurse collects a great deal of data and information. The amount of data and information may exceed the amount the nurse can process efficiently and correctly. Thus, the nurse needs assistance to become proficient in the planning of nursing care, due to the difficulty of simultaneously processing a large set of information. Computer systems are viewed as tools to expand the capabilities of the nurse's mind. Using computer technology to support clinicians' decision making may provide high-quality, patient-centered, and efficient healthcare. Although some existing nursing information systems aid in the nursing process, they only provide the most fundamental decision support--i.e., standard care plans associated with common nursing diagnoses. Such a computerized decision support system helps the nurse develop a care plan step-by-step. But it does not assist the nurse in the decision-making process. The decision process about how to generate nursing diagnoses from data and how to individualize the care plans still reminds of the nurse. The purpose of this study is to develop a pilot structure in electronic nursing record system integrated with international nursing standard for improving the proficiency and accuracy of plan of care in clinical pathway process. The proposed pilot systems not only assist both student nurses and nurses who are novice in nursing practice, but also experts who need to work in a practice area which they are not familiar with.
评估、诊断、计划、干预和评价。在护理程序中,护士收集大量的数据和信息。数据和信息的数量可能超过护士能够有效且正确处理的量。因此,由于同时处理大量信息存在困难,护士在精通护理计划制定方面需要协助。计算机系统被视为扩展护士思维能力的工具。利用计算机技术支持临床医生的决策制定可以提供高质量、以患者为中心且高效的医疗服务。尽管现有的一些护理信息系统有助于护理程序,但它们仅提供最基本的决策支持——即与常见护理诊断相关的标准护理计划。这样的计算机化决策支持系统帮助护士逐步制定护理计划。但它在决策过程中并不协助护士。关于如何从数据中生成护理诊断以及如何使护理计划个性化的决策过程仍然依赖护士。本研究的目的是在电子护理记录系统中开发一个与国际护理标准相结合的试点结构,以提高临床路径过程中护理计划的熟练度和准确性。所提议的试点系统不仅有助于实习护士和护理实践新手,也有助于需要在不熟悉的实践领域工作的专家。