摘要
目的:构建导管护理结构化记录系统,融合智能辅助决策功能,以提升护理记录的规范性与准确性,提高护理文书质量和数据利用价值。方法:通过构建导管护理结构化记录知识库,形成包括胃管、尿管、中心静脉导管、经外周静脉置入中心静脉导管、气管导管在内的全流程管理结构化记录系统,于2024年6月—12月在北京市某三级甲等医院的15个科室进行应用。邀请专家对系统内容进行评价,并调查系统在临床应用后的使用率、系统可接受性以及非计划拔管监测准确率。结果:专家对导管记录客观性、准确性、规范性、重要性评价的平均分为(4.83±0.21)分;系统使用率为94.50%;系统可接受性问卷中各条目平均分在(4.39±0.75)分及以上,满意度在90%以上。监测平台检出准确率由1.73%提高至6.30%,差异有统计学意义(P<0.05)。结论:护士对导管护理结构化记录系统接受度和满意度较高;系统的运用提高了护理记录的规范性和数据质量,优化了决策支持能力,具有较好的可推广性,对提高护理质量具有重要意义。
Objective:To develop a structured catheter care documentation system integrated with intelligent decision support functions,aiming to enhance the standardization and accuracy of nursing records,improve the quality of nursing documentation,and increase the value of data utilization.Methods:A structured catheter care documentation knowledge base was built,encompassing the full management process of gastric tubes,urinary catheters,central venous catheters,peripherally inserted central catheters,and endotracheal tubes.The system was implemented across 15 departments in a tertiary grade A hospital in Beijing from June to December 2024.Experts were invited to evaluate the system's content,and a survey was conducted to assess the system's usage rate,acceptability,and the detection accuracy of the unplanned extubation monitoring platform.Results:The average expert evaluation score for the objectivity,accuracy,standardization,and importance of catheter care documentation was 4.83±0.21.The system usage rate was 94.50%.In the system acceptability survey,the average score of all items was 4.39±0.75 or higher,with a satisfaction rate of 90%.The detection accuracy of the monitoring platform increased from 1.73%to 6.30%,with significant differences(P<0.05).Conclusion:Nurses show high acceptability of the structured catheter care documentation system.The system significantly improve the standardization and quality of nursing records,optimize decision support capabilities,and demonstrate good potential for broader application.It plays an important role in improving nursing quality.
作者
胡敬利
马燕兰
常荣
程艳爽
宋海楠
程少荣
HU Jingli;MA Yanlan;CHANG Rong;CHENG Yanshuang;SONG Hainan;CHENG Shaorong(Chinese People's Liberation Army Medical School,Beijing,100853,China)
出处
《中国护理管理》
北大核心
2025年第5期786-790,共5页
Chinese Nursing Management
基金
军事医学创新工程专项(18CXZ035)。
关键词
导管护理
结构化
护理记录
智能辅助决策
数据质量
catheter care
structured
nursing record
intelligent decision support
data quality
