臺北市某區域型醫院護理過程決策輔助系統之建置

Establishment of Nursing Process Decision Support Information System (NPDSIS) in a Taipei Regional Hospital

蔡惠華(Hui-Hua Tsai) ； 馮容莊(Rung-Chuang Feng)

《北市醫學雜誌》 16卷3期 (2019/09) Pp. 244-254

https://doi.org/10.6200/TCMJ.201909_16(3).0007

摘要

背景與目的：隨著醫療資訊科技發展與進步，護理資訊系統的建置是必然之趨勢，而決策輔助系統更是臨床工作者的最佳利器，足以優化護理照護、精簡紀錄流程與縮短文書時間。因此，本專案計畫擬建立一臨床護理過程的決策輔助系統，以提供護理師臨床判斷與決策的參考與建議。對象與方法: 臺北市某區域型醫院既有護理計畫系統（Nursing care plan system）為勾選式，而護理紀錄則以SOAIE格式手寫方式執行。本專案之護理過程決策輔助之系統規劃乃以Verginia Saba（2012）所發展的臨床照護分類系統（Clinical Care Classification，CCC2.5）為經，護理診斷分類系統（Northern American Nursing Diagnosis；NANDA）及護理措施分類系統（Nursing Intervention Classification，NIC）為緯，以護理過程架構建置護理診斷、措施與評值，並完成護理指導與護理技術之連結。自2016年底著手進行系統規劃，2018年10月完成系統設計、建置、測試、上線操作，亦將護理診斷與紀錄轉為電子簽章與電子病歷，完成護理電子病歷的建置。結果：專案建構的護理過程系統（Nursing Process Decision Support Information System，NPDSIS），乃運用臨床照護分類系統臺灣版臨床照護分類（Clinical Care Classification in Taiwan version，TW-CC）編碼系統為架構，護理入院評估建置成人、新生兒、精神科，中醫四種版本；護理評估系統乃依據Gordon十一項健康功能評估項目，又配合醫院政策與臨床需要，增列衰弱評估、自殺評估、出備篩檢、安寧需求評估等項目；護理診斷／健康問題以臨床常見問題建置了61項，歸類為心理部份（20項）與生理部份（41項），其中增列中醫專科診斷6項；護理措施則建置117項，包括生理部份93項與心理部份24項；護理結果評值則以症狀改善、維持／穩定、惡化等三項目呈現，並書寫於護理紀錄中。本案護理過程決策輔助系統的設計與建構，滿足了以下八大特色，包括「專科化」、「個別化」、「結構式」、「非結構式」、「連結性」、「操作性」、「決擇性」、「延展性」。未來本案系統的持續建置將朝實證護理資料庫的建立與應用、護理大數據的分析與護理新知識的建構，如此將引領護理專業走向精實、有效與高品質的境界。

關鍵字

護理過程決策輔助系統 ； 臨床照護分類系統

並列摘要

Background and objectives: Establishment of nursing information system is inevitable along with the development and progress of medical information technology. Decision assistance system that optimizes nursing care, simplifies the record process, and shortens the paperwork, is the best tool for clinical workers. This project planned to establish a nursing process decision support information system (NPDSIS) to provide references and recommendations for clinical decision-making. Participants and methods: A Nursing care plan information system with nursing record performed in SOAIE format by handwriting had preexisted in a regional hospital in Taipei. In the current project, the new decision assistance system was constructed with the clinical care classification (CCC 2.5) as longitude, the North American Association nursing diagnosis (NANDA) and nursing intervention classification (NIC) as latitude, and the nursing process as main frame to build up the contents of nursing diagnosis, measure, and evaluation. Also, nursing guidelines and skills are linked-up. The planning of this project began at the end of 2016. The system design, construction, testing, and online operation were completed in October 2018. Also, nursing diagnosis and records were converted into electronic signature and records. The establishment of nursing records were thus accomplished. Result: The architecture of this NPDSIS applies the Taiwan version of the Clinical Care Classification System (TW-CC) coding system as its framework, and consists four versions of admission nursing assessment, namely, adult, newborn, psychiatric, and Chinese medicine. In line with the hospital policies and clinical needs, fragile assessment, suicide assessment, discharge planning screen, and palliative needs assessment have been amended to the nursing assessment system which is based on the items of Gordon 11 health function. The section of nursing diagnoses and health problems comprises 61 items including 20 psychological items and 41 physical items. Also 6 Chinese medicine nursing diagnoses items have been amended to the system. The section of nursing interventions comprises 117 items, of which 93 items were physical nursing interventions, and the other 24 were psychological nursing interventions. The nursing outcome assessments are revealed as symptom improvement, maintenance/stabilization, and deterioration, which are recorded in the nursing records. The design and construction of NPDSIS in this project meet the eight features - specialization, individuality, formatting, non-formatting, connected, operational, selective, and malleability. In the future, the continuous construction of NPDSIS will navigate to the establishment and application of evidence-based nursing database, analysis of nursing big data, and construction of new nursing knowledge. This will result in leading the nursing profession to the realm of refinement, effectiveness, and high quality.

並列關鍵字

Nursing Process Decision Support Information System ； Clinical Care Classification