CN103455963A - Specific disease nursing system with DGRs as guidance based on wireless handheld terminal - Google Patents
Specific disease nursing system with DGRs as guidance based on wireless handheld terminal Download PDFInfo
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- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 title claims abstract description 42
- 201000010099 disease Diseases 0.000 title claims abstract description 41
- 238000011156 evaluation Methods 0.000 claims abstract description 38
- 238000012549 training Methods 0.000 claims description 72
- 206010025482 malaise Diseases 0.000 claims description 48
- 238000004891 communication Methods 0.000 claims description 6
- 230000003203 everyday effect Effects 0.000 claims description 6
- 239000003550 marker Substances 0.000 claims description 3
- 238000000034 method Methods 0.000 abstract description 14
- 238000012423 maintenance Methods 0.000 description 5
- 206010020772 Hypertension Diseases 0.000 description 3
- 238000013461 design Methods 0.000 description 3
- 206010012601 diabetes mellitus Diseases 0.000 description 2
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- 206010011985 Decubitus ulcer Diseases 0.000 description 1
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- 230000035764 nutrition Effects 0.000 description 1
- 235000016709 nutrition Nutrition 0.000 description 1
- 230000001737 promoting effect Effects 0.000 description 1
- 238000011002 quantification Methods 0.000 description 1
- 230000029058 respiratory gaseous exchange Effects 0.000 description 1
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Abstract
Disclosed is a specific disease nursing system with DGRs as the guidance based on a wireless handheld terminal. The specific disease nursing system comprises a PDA nursing terminal, an HIS medical treatment platform and a hospital management platform, wherein the PDA nursing terminal comprises a specific disease nursing module and a nursing evaluation module, the HIS medical treatment platform comprises a background service database used for storing the specific disease nursing content and various nursing evaluation forms, and the hospital management platform comprises a specific nursing knowledge base used for storing specific disease information, nursing schemes and nursing evaluation information, and allowing a nurse to retrieve the specific disease information, the nursing schemes and the nursing evaluation information. The PDA nursing terminal, the HIS medical treatment platform and the hospital management platform are mutually connected through a network to achieve data sharing. According to the specific disease nursing system, the PDA nursing terminal is adopted to be connected with the specific nursing knowledge base through the wireless network of a hospital, the nurse can conduct relevant operations according to the set nursing procedure by checking nursing prompts displayed on the PDA nursing terminal, the accuracy and standardization of the nursing procedure and the nursing evaluation are ensured, the professional standards of the nurse are improved, the nursing cost is reduced, and the problem that the nursing procedure and the nursing execution can not be tracked and managed is solved by the application of the information system.
Description
Technical field
The present invention relates to medical care, particularly a kind of based on wireless handheld terminal take DGRs as the guiding training sickness nursing system.
Background technology
The nursing development pole of training disease is important, but the cultivation of clinical nurse specialism and use are still in the starting stage.Clinical nursing activity is mainly set up Standard Nursing flow process and the specific nursing measure of papery by head nurses at present, strengthen nurse's training level by study or education, but due to the clinical nursing activity amount and labour intensity powerful, nurse's ability and experience are variant, cause the nurse when carrying out nursing flow process, training sickness nursing, weak link occurs, nursing error even occurs, directly reduce nursing quality and patient satisfaction, indirectly bring more expensive to patient.For promoting construction and the standardized management of training disease, improve nurse's Specialty knowledge level, realize really the time being returned to patient, necessary proposition is a kind of take the training sickness nursing system that medical diagnosis on disease associated packets (DRGs) is guiding, to following the tracks of timely and accurately the progress of each nursing link.
Summary of the invention
Fundamental purpose of the present invention is to overcome above-mentioned shortcoming of the prior art, propose a kind of formulate professional nursing flow process, care regimen, nursing assess and unified maintenance management based on wireless handheld terminal take DGRs as the guiding training sickness nursing system.
The present invention adopts following technical scheme:
The DGRs of take based on wireless handheld terminal is the training sickness nursing system led, and it is characterized in that: comprise
The PDA nursing terminal, comprise training sickness nursing module for create and carry out care regimen according to patient's state of an illness and for assessment of the nursing evaluation module of the implementation status of this care regimen;
HIS medical treatment platform, comprise for storing the background service database of training sickness nursing content and various nursing assessment list;
The hospital management platform, comprising can be for the specific nursing knowledge base of training disease information, care regimen and the nursing appreciation information retrieved for storage;
Connect and realize data sharing by network between this PDA nursing terminal, HIS medical treatment platform and hospital management platform; This PDA nursing terminal accesses the specific nursing knowledge base of hospital management platform by wireless network, retrieve and show that set care regimen and nursing appreciation information are also respectively as training sickness nursing operating basis, nursed evaluation operation, and the executive logging of the operation of training sickness nursing and nursing evaluation operation is stored in the background service database of HIS medical treatment platform, for statistics and management.
Further, described training sickness nursing module comprise show and can be for the newly-increased care regimen unit of operation, carry out the nursing content unit, complete the care regimen unit and interrupt the care regimen unit.
Further, described nursing evaluation module comprises demonstration and can supply the interpolation of operation nurse assessment unit, project evaluation unit, the rear quantification mark unit automatically of assessment and generate the assessment text unit every day.
Further, the training sickness nursing content of described background service database at least comprises one or more in training disease category dictionary, schedule dictionary, training disease noun dictionary.
Further, the various nursing of described background service database assessment lists at least comprise that assessment used record sheet, training sickness nursing to record master meter, training sickness nursing and use and record one or more in master meter.
Further, one or more in a name dictionary, evaluation item are used record sheet at least to comprise and assess list, evaluation item list, assess in described assessment.
Further, the training disease information of described specific nursing knowledge base comprises training disease name, stage schedule, effective marker, operation sign.
Further, the care regimen of described specific nursing knowledge base comprises stage schedule, nursing items and the contents of a project, and a disease that calls for specialized treatment care regimen can be divided into a plurality of nursing stage schedules, under each nursing stage schedule, divides again a plurality of nursing items and the contents of a project.
Further, the nursing assessment of described specific nursing knowledge base comprises that the nursing evaluation item is safeguarded, nursing assessment inventory is safeguarded and nursing assessment distribution, a training sickness nursing assessment can have a plurality of evaluation items, and each evaluation item has a plurality of sub-projects.
Further, also comprise the slow sick care management system in community and electronic medical record system, the slow sick care management system in this community is connected communication with electronic medical record system with the hospital management platform.
From the above-mentioned description of this invention, compared with prior art, the present invention has following beneficial effect:
1, specific nursing knowledge base of the present invention is diagnosed associated packets based on DRGs() the training disease is carried out to classified finishing, and formulate professional nursing flow process, care regimen, nursing estimation items, and unified maintenance management by the hospital management platform, the nursing experiences of replaced existing paper records, even passing from mouth to mouth, the problem of solution nursing knowledge management maintenance difficulty.
2, the PDA nursing terminal is by the wireless network of hospital, connect the specific nursing knowledge base, utilize the portability of PDA nursing terminal, retrieve the nursing procedure information of relevant disease whenever and wherever possible and show, the nursing prompting that the nurse shows by checking the PDA nursing terminal, according to set nursing flow process, the enterprising line correlation operation at PDA nursing terminal interface, guarantee to nurse flow process, the accuracy of nursing assessment, standardization, meet special circumstances (as patient has past medical history, allergies), need to fill in non-conformance description, the executive logging of care regimen and assessment with digitized form permanent storage to the background service database.Improve nurse's professional standards, reduce nursing cost, exploit information system solution nursing flow process, nurse the problem that can't follow the tracks of, manage of carrying out.
3, by the Data Enter of PDA nursing terminal, all data all structured storage, to the background service database, can be nursed details to each and carry out relevant inquiring, statistical operation, for head nurses provides decision data support accurately.
The accompanying drawing explanation
Fig. 1 be of the present invention based on wireless handheld terminal take DGRs as the guiding training sickness nursing system schematic;
Fig. 2 be take the structured flowchart of DGRs as the training sickness nursing system of guiding for this is clearly demarcated based on wireless handheld terminal;
The function composition module map that Fig. 3 is the PDA nursing terminal;
The function composition module map that Fig. 4 is the background service database;
The function composition module map that Fig. 5 is the specific nursing knowledge base;
The care regimen example schematic that Fig. 6 is the specific nursing knowledge base;
The nursing appreciation information example schematic that Fig. 7 is the specific nursing knowledge base;
The operation example schematic that Fig. 8 is the PDA nursing terminal (care regimen execution);
The operation example schematic (non-conformance description) that Fig. 9 is the PDA nursing terminal;
The operation example schematic that Figure 10-Figure 12 is the PDA nursing terminal (repeating care regimen and nursing assessment);
Figure 13 is the example schematic of down-transmitting data to the slow sick care management system in community;
Figure 14 is the slow sick care management system example schematic in community of the present invention;
The management that Figure 15 is background service database of the present invention and statistics example schematic.
Embodiment
Below by embodiment, the invention will be further described.
With reference to Fig. 1, Fig. 2, the DGRs of take based on wireless handheld terminal is the training sickness nursing system led, and comprises following several part:
1, PDA nursing terminal
The PDA nursing terminal be have operation interface, can radio communication portable hand-held terminal device, it comprises training sickness nursing module for create and carry out care regimen according to patient's state of an illness and for assessment of the nursing evaluation module of the implementation status of this care regimen.
Wherein, with reference to Fig. 3 training sickness nursing module specifically comprise according to the needs of patient's state of an illness create care regimen newly-increased care regimen unit, according to the care regimen content carry out executable operations execution nursing content unit, complete the care regimen unit, interrupt the care regimen unit and under pass to the slow sick care management system in community, in carrying out the nursing content process, if patient's state of an illness changes and can increase corresponding nursing and arrange schedule and nursing intervention, and non-conformance description is registered.Complete or interrupt the nursing after, also can will under the implementation status of care regimen, pass in the slow sick care management system in community as required.
This nursing evaluation module comprises that project evaluation unit that the interpolation that the care regimen according to patient carries out nursing evaluation operation every day nurses assessment unit, each care regimen subordinate's detailed programs are assessed every day, the assessment that assessment data is carried out to statistical treatment automatically quantize afterwards the mark unit and generate the assessment text unit, and the assessment content of each assessment unit can be carried out later maintenance and renewal as required.
2, HIS medical treatment platform
With reference to Fig. 4, HIS medical treatment platform comprises for storing the background service database of training sickness nursing content and various nursing assessment list.Wherein, training sickness nursing content includes training disease category dictionary, schedule dictionary, training disease noun dictionary etc.Various nursing assessment lists comprise that assessment is used record sheet, training sickness nursing to record master meter, the training sickness nursing is used and records master meter etc.Assessment is used record sheet to comprise assessment list, evaluation item list, assessment name dictionary, evaluation item dictionary etc., and assessment is used record sheet can be converted into the assessment result view.Information in above-mentioned background service database can be called as required or upgrade.
3, hospital management platform
With reference to Fig. 5, the hospital management platform comprises for storing the specific nursing knowledge base of training disease information, care regimen and nursing appreciation information, this specific nursing knowledge base is based on DRGS diagnosis associated packets the training disease is carried out to classified finishing, and formulates the nursing flow process, care regimen, nursing estimation items etc. of training disease.
Wherein, the training disease information of storage comprises training disease name, stage schedule, effective marker, operation sign.The care regimen of storage comprises stage schedule, nursing items and the contents of a project, a disease that calls for specialized treatment care regimen can be divided into a plurality of nursing stage schedules, divide again a plurality of nursing items and the contents of a project under each nursing stage schedule, as: with reference to Fig. 6, be admitted to hospital the same day, while in hospital, leave hospital etc., stage name can be according to the self-defined setting of disease that calls for specialized treatment feature, divide again a plurality of nursing items and the contents of a project under each nursing stage, and the hierarchical relationship of self-defined content item as required, " ## " represents the most top classification.
The nursing assessment of storage comprises the maintenance of nursing evaluation item, nursing assessment inventory safeguards and distribution etc. is assessed in nursing, and the nursing assessment is the basis of whole care program, is an important content of Nursing administration.The nurse by nursing assess content, sequentially, the time can be system, continuous, objective and accurate the process of the collection patient analysis judgement state of an illness, improve quality of nursing management, prevent trouble before it happens.Distribution nursing assessment can be normalized for the patient works out nursing care plan and therapeutic scheme, for Implementing decision-making and intervention provide the foundation of science.The assessment of training sickness nursing can have a plurality of evaluation items, and each evaluation item can have a plurality of sub-projects, analyzes from different perspectives the patient health situation, is conducive to strengthen the patient clinical nursing quality.For example, with reference to Fig. 7, certain disease that calls for specialized treatment nursing assessment comprises admission assessment, hypertension assessment, the unexpected assessment of hazards and pressure sore risks evaluation, and admission assessment wherein comprises heart rate and the rhythm of the heart, breathing, mind, nutrition, activity, sleep etc.
4, electronic medical record system
This electronic medical record system is connected communication with the hospital management platform, for generating electronic health record.
5, the slow sick care management system in community
The slow sick care management system in this community is connected communication with the hospital management platform, and the hospital management platform can reach the slow sick care management system in community by slow sick (hypertension, diabetes) nursing data as required.
Can carry out data sharing and communicate by letter by the hospital internal network between PDA nursing terminal of the present invention, HIS medical treatment platform, hospital management platform, the slow sick care management system of electronic medical record system and community.Below illustrate principle of work of the present invention:
1, the execution of care regimen
The nurse carries the PDA nursing terminal, whenever and wherever possible by the wireless network access hospital management platform of hospital internal, call the specific nursing knowledge base according to patient's the state of an illness, retrieve set training disease information, care regimen and nursing appreciation information, and the set care regimen shown according to terminal is carried out the Related Nursing operation, and be recorded on the PDA nursing terminal, as because partly cause, can not carry out by set care regimen, can select " not carrying out ", the reason that system can require record not carry out, make nursing have evidence, can review, as Fig. 8, Fig. 9.
2, the execution of nursing assessment
The nursing evaluation module of PDA nursing terminal adopts the combobox design, shows that nursing assessment, the project evaluation, assessment every day automatically quantizes afterwards mark and generate assessment text etc., facilitates the nurse to be nursed the assessment result registration.
3, repeat care regimen and nursing assessment every day
The nurse, according to patient's situation, is copied care regimen, nursing assessment, and is shown with " [date] [project name] " format, as Figure 10, Figure 11, Figure 12, and records respectively operating result, reaches the purpose that special disease is repeatedly nursed execution.
4, the inside and outside data sharing of system with synchronize
PDA nursing terminal, HIS medical treatment platform and hospital management platform are realized in system data sharing and are synchronizeed by communication interface separately.The PDA nursing terminal can be stored to the executive logging of the operation of training sickness nursing and nursing evaluation operation in the background service database of HIS medical treatment platform, also slow disease (hypertension, diabetes) nursing data wherein can be reached to the outer slow sick care management system in community of system, with reference to Figure 13, Figure 14.
5, nursing supervision and statistics
By the Data Enter of PDA nursing terminal, all data all structured storage, to the background service database, can be nursed details to each and carry out relevant inquiring, statistical operation, for head nurses provides decision data support accurately.System of the present invention also can realize following statistical function: according to the access nurse of disease that calls for specialized treatment, can add up the training sickness nursing number that the nurse adds; According to the state of training disease, can add up the training sickness nursing number of carrying out; Can add up according to stopping nurse's field the training sickness nursing number stopped midway; The training disease people that can add up each section office according to the section office of access nurses number, with reference to Figure 15.
Above are only the specific embodiment of the present invention, but design concept of the present invention is not limited to this, allly utilizes this design to carry out the change of unsubstantiality to the present invention, all should belong to the behavior of invading protection domain of the present invention.
Claims (10)
1. the DGRs of take based on wireless handheld terminal is the training sickness nursing system led, and it is characterized in that: comprise
The PDA nursing terminal, comprise training sickness nursing module for create and carry out care regimen according to patient's state of an illness and for assessment of the nursing evaluation module of the implementation status of this care regimen;
HIS medical treatment platform, comprise for storing the background service database of training sickness nursing content and various nursing assessment list;
The hospital management platform, comprising can be for the specific nursing knowledge base of training disease disease information, care regimen and the nursing appreciation information retrieved for storage;
Connect and realize data sharing by network between this PDA nursing terminal, HIS medical treatment platform and hospital management platform; This PDA nursing terminal accesses the specific nursing knowledge base of hospital management platform by wireless network, retrieve and show that set care regimen is with the nursing appreciation information and as training sickness nursing operating basis, nursed evaluation operation, and the executive logging of the operation of training sickness nursing and nursing evaluation operation is stored in the background service database of HIS medical treatment platform, for statistics and management.
2. the DGRs of take based on wireless handheld terminal as claimed in claim 1 is to it is characterized in that the training sickness nursing system of guiding: described training sickness nursing module comprise show and can be for the newly-increased care regimen unit of operation, carry out the nursing content unit, complete the care regimen unit and interrupt the care regimen unit.
3. the DGRs of take based on wireless handheld terminal as claimed in claim 1 is to it is characterized in that the training sickness nursing system of guiding: described nursing evaluation module comprise show and can nurse assessment unit, project evaluation unit, assessment every day for the interpolation of operation after automatically quantize the mark unit and generate the assessment text unit.
4. the DGRs of take based on wireless handheld terminal as claimed in claim 1 is the training sickness nursing system led, and it is characterized in that: the training sickness nursing content of described background service database at least comprises one or more in training disease category dictionary, schedule dictionary, training disease noun dictionary.
5. the DGRs of take based on wireless handheld terminal as claimed in claim 1 is to it is characterized in that the training sickness nursing system of guiding: the various nursing assessment lists of described background service database at least comprise that assessment used record sheet, training sickness nursing to record master meter, training sickness nursing and use and record one or more in master meter.
6. the DGRs of take based on wireless handheld terminal as claimed in claim 5 is the training sickness nursing system led, and it is characterized in that: one or more in a name dictionary, evaluation item are used record sheet at least to comprise and assess list, evaluation item list, assess in described assessment.
7. the DGRs of take based on wireless handheld terminal as claimed in claim 1 is the training sickness nursing system led, and it is characterized in that: the training disease information of described specific nursing knowledge base comprises training disease name, stage schedule, effective marker, operation sign.
As claimed in claim 1 based on wireless handheld terminal take DGRs as the guiding training sickness nursing system, it is characterized in that: the care regimen of described specific nursing knowledge base comprises stage schedule, nursing items and the contents of a project, a training sickness nursing scheme can be divided into a plurality of nursing stage schedules, under each nursing stage schedule, divides again a plurality of nursing items and the contents of a project.
As claimed in claim 1 based on wireless handheld terminal take DGRs as the guiding training sickness nursing system, it is characterized in that: the nursing assessment of described specific nursing knowledge base comprises that the nursing evaluation item is safeguarded, nursing assessment inventory is safeguarded and nursing assessment distribution, a disease that calls for specialized treatment nursing assessment can have a plurality of evaluation items, and each evaluation item has a plurality of sub-projects.
As claimed in claim 1 based on wireless handheld terminal take DGRs as the guiding training sickness nursing system, it is characterized in that: also comprise the slow sick care management system in community and electronic medical record system, the slow sick care management system in this community is connected communication with electronic medical record system with the hospital management platform.
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Application publication date: 20131218 |