Design and application of nursing clinical decision support system based on structured electronic medical records / 中国实用护理杂志

ABSTRACT

Objective Establishing intelligent nursing clinical decision support system to improve the safety, quality and efficiency of clinical nursing work. Methods Guided by the HIMSS EMRAM Analytics stage 7 evaluation standard, the nursing decision support system is continuously improved through the establishment of knowledge bases such as nursing plans and nursing conventions. Results By comparing the writing time of nursing documents, the correct rate of nursing diagnosis, and the incidence of nursing risk events before and after the used of the system, the results showed that after the used of the nursing decision-making support system, whole hospital′s writing time could save 222.5 hours per day, improved accuracy of nursing diagnosis from 68.33％ (205/300)to 90.67％ (272/300), the difference was statistical significace (χ2=45.907, P<0.05). Decreased incidents, hospital-wide, on falls from 0.127‰(80/631702) to 0.071‰(45/638715),and on pressure ulcer form 0.064‰ (41/631702)to 0.028‰(18/638715), the difference was statistical significace (χ2=13.004～15.071, P<0.05). Conclusion Nursing clinical decision support system is the trend of hospital informatization and is worthy of clinical application.