醫學診斷輔助護理過程支援系統

Medical Diagnosis Assisted Nursing Process Support System

賴燕賢(Yen-Hsien Lai) ； 劉立(Li Liu) ； 徐建業(Chien-Yeh Hsu) ； 陳俊賢(Jiun-Shyan Chen)

《新臺北護理期刊》 3卷1期 (2001/02) Pp. 67-78

https://doi.org/10.6540/NTJN.2001.1.008

摘要

隨著資訊科技的進步，電腦在醫療上的應用備受重視，支援系統或專家系統已漸成為醫療人員的次要意見（second opinion），其重要性可見一般。而在病患照護中，醫護理人員須透過專業知識與評估技巧去收集資料、確立護理診斷、擬定護理計劃。由於護理過程中需要許多的資訊，幫助臨床判斷與決策，因此護理資訊系統乃應運而生。然現有之資訊系統僅提供整齊美觀、一致格式的護理計畫表單，對於確立護理診斷時，受限於護理人員本身之知識、經驗或憑乎直覺之決定及缺乏精密思考（critical thinking）的推論過程，而影響診斷的完整性與正確性之缺失，尚無對策。
本研究提出一醫學診斷輔助護理過程模式（Medical Diagnosis Assisted Nursing Process Model），透過醫師診斷的輔助，發展以各病患為中心（Patient Centered）之評估工具，輔以自動化評估轉換之推論機制，完成Web-based護理過程支援系統，期能藉助資訊科技的優勢，讓病患之照護過程與資料透明化，彰顯護理之貢獻。
本系統不僅能提昇執行護理評估的確實度，建立其至護理診斷確認之具體過程，更有助於護理人員確立護理診斷（Diagnosis）的正確性與完整性及擬定切合該診斷之護理措施，此護理措施在未來更可進一步成為該護理診斷之照護標準。而護理史之電腦化，讓護理人員無需重複收集和書寫病史，提高了資料的完整性與連續性。此外，護理診斷決策支援系統的建立，得以縮短臨床與學理之差距，幫助護理教學的具體化，而在護理研究上更有助於病患照護資料的收集與分析。總之，護理資訊化之發展勢在必行，更是實證護理實務之礎石。

關鍵字

護理過程 ； 護理診斷 ； 護理資訊學 ； 護理過程支援系統

並列摘要

Advances of computer technology brings new medical information system for consideration. The use of an expert system or decision support system to provide a second opinion for most of the healthcare providers, indicates high performance in medical information systems today. In nursing care, nurses use expertise and assessment skills instead of inference through critical thinking to make nursing diagnoses and care plans. But in the nursing process, more information is needed to make decision and judgement. Nevertheless almost all existing care planning systems only provide sheets of uniform forms to fill in with nursing plans.
The goal of our research is to suggest the Medical Diagnosis Assisted Nursing Process Model which is a web-based Nursing Process Support System consisting of physician-diagnosis-aided, patient-centered evaluation tools. These evaluation tools are primarily inference mechanisms to convert assessment into diagnosis automatically.
The virtues of our Nursing Process Support System include higher assessment accuracy and more concrete flows from assessment to diagnosis. It helps the nurses to identify diagnosis and proper intervention which will also become caring standards. Computerization of nursing history allows nurses to get rid of the duplication in recording patient history to improve completeness and consistency of documents. It can be seen that putting theory into practice with the aid of Nursing Process Support Systems will in turn make a breakthrough in nursing teaching and research.

並列關鍵字

nursing process ； nursing diagnosis ； nursing informatics ； nursing process support system