Abstract:

Objective To construct a nursing consultation information system based on consultation process and information interaction needs and explore its application effect. Methods The nursing consultation process and information interaction needs were analyzed；the information process，content modules and information interaction interface were designed；the structured records for nursing consultation were developed. The system was officially applied in January 2024. The application effect was evaluated by comparing the completion time of nursing consultations，nursing consultation record quality score，nursing consultation evaluation completion rate，and satisfaction rate before（August 2023 to October 2023） and after（January 2024 to March 2024） the application of the information system. Results After the application of the nursing consultation information system，the implementation rate of nursing consultation for inpatients increased from 1.27% before the application of the system to 1.47%（P=0.019）. The completion time of nursing consultation in the whole hospital reduced from 351（225，421） minutes before the application of the system to 310（156，402） minutes（P<0.001），and there was a statistically significant difference in the completion time of nursing consultation among the 3 specialties of intravenous therapy，blood purification，and diabetes nursing（P<0.05）. The quality score of nursing consultation records increased from 90.5（82.0，100） points to 95.5（92.0，100） points（P<0.001）. The completion rate of nursing consultation evaluation was higher than those before the system application，with statistical significance（21.6% vs 78.4%，P<0.001）. Conclusion Nursing consultation information system based on information interaction needs can improve the implementation of nursing consultation for inpatients，shorten the completion time of nursing consultations，improve the writing quality of nursing consultation records and the completion rate of nursing consultation evaluation，and it succeeded in real-time quality monitoring.

Key words: Consultation, Information System, Nursing Administration Research

摘要：

目的 基于信息交互需求，开发护理会诊信息系统，并评价其应用效果。方法 成立系统研发团队，分析护理会诊流程及信息交互需求，设计信息化流程、内容模块及信息交互界面，开发护理会诊信息系统。该系统于2024年1月在北京市某三级甲等综合医院正式应用，通过比较信息系统应用后（2024年1月—3月）与应用前（2023年8月—10月）的住院患者护理会诊比例、护理会诊完成时间、护理会诊记录质量评分、护理会诊双向评价完成率及满意率来评价系统的应用效果。结果 护理会诊信息系统包括会诊申请及应答2个平台。其中，会诊应答平台包括会诊指派、会诊接收、会诊签到、会诊记录、会诊评价、数据统计及会诊管理7个模块，可与医院信息系统、护理信息系统、检验信息系统等多系统交互。信息系统应用后，住院患者护理会诊比例由系统应用前的1.27%提高至1.47%（P=0.019）；护理会诊完成时间由系统应用前的351（225，421） min缩短至310（156，402） min（P<0.001），其中静脉治疗、血液净化、糖尿病护理3个专业组的护理会诊完成时间与系统应用前比较，差异具有统计学意义（均P<0.05）；护理会诊记录质量评分由系统应用前的90.5（82.0，100）分提升至95.5（92.0，100）分（P<0.001）；护理会诊双向评价完成率由系统应用前的21.6%升高至78.4%（P<0.001）。信息系统应用前后，护理会诊双向评价满意率均为100%。结论 该研究基于信息交互需求开发了护理会诊信息系统。应用该系统可促进住院患者护理会诊的开展、缩短护理会诊完成时间、提高护理会诊记录质量及双向评价完成率，并实现护理会诊质量实时管理。

关键词: 会诊, 信息系统, 护理管理研究