本文選題：電子護(hù)理文書(shū) + 質(zhì)量控制��； 參考：《南昌大學(xué)》2017年碩士論文

【摘要】：目的:研究開(kāi)發(fā)電子護(hù)理文書(shū)實(shí)時(shí)質(zhì)控系統(tǒng),實(shí)現(xiàn)對(duì)電子護(hù)理文書(shū)時(shí)效性?xún)?nèi)容進(jìn)行程序自動(dòng)監(jiān)控,內(nèi)涵質(zhì)量進(jìn)行基于質(zhì)控系統(tǒng)的后臺(tái)人工監(jiān)控,對(duì)監(jiān)控結(jié)果進(jìn)行實(shí)時(shí)反饋、存儲(chǔ)、統(tǒng)計(jì)和分析,提升電子護(hù)理文書(shū)質(zhì)控效率、質(zhì)控手段和質(zhì)量管理水平。同時(shí)構(gòu)建電子護(hù)理文書(shū)質(zhì)控指標(biāo)體系,為基于質(zhì)控系統(tǒng)檢查電子護(hù)理文書(shū)、量化評(píng)定電子護(hù)理文書(shū)質(zhì)量提供客觀、科學(xué)的評(píng)價(jià)標(biāo)準(zhǔn)。方法:本研究分兩個(gè)部分。第一部分:電子護(hù)理文書(shū)質(zhì)控指標(biāo)體系的研究。在查閱大量課題相關(guān)文獻(xiàn)、書(shū)籍和專(zhuān)家訪談的基礎(chǔ)上初步擬定電子護(hù)理文書(shū)質(zhì)控指標(biāo)體系。初步擬定的電子護(hù)理文書(shū)質(zhì)控指標(biāo)體系,通過(guò)Delphi法對(duì)18名來(lái)自醫(yī)院管理、護(hù)理管理和臨床護(hù)理的專(zhuān)家進(jìn)行2輪專(zhuān)家咨詢(xún),利用Excle2003、SPSS17.0軟件對(duì)咨詢(xún)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析,指標(biāo)篩選遵循重要性賦值≥3.5、變異系數(shù)0.25和專(zhuān)家建議原則。指標(biāo)權(quán)重的確立根據(jù)第二輪專(zhuān)家打分采用定量統(tǒng)計(jì)法確定。通過(guò)頻數(shù)、構(gòu)成比對(duì)專(zhuān)家一般資料進(jìn)行統(tǒng)計(jì)描述,采用問(wèn)卷回收率(%)、權(quán)威系數(shù)判定專(zhuān)家對(duì)本研究的積極性和權(quán)威程度,專(zhuān)家意見(jiàn)的協(xié)調(diào)程度用變異系數(shù)和肯德?tīng)?Kendall)協(xié)調(diào)系數(shù)表示,通過(guò)上述指標(biāo)檢驗(yàn)Delphi法構(gòu)建的電子護(hù)理文書(shū)質(zhì)控指標(biāo)體系的科學(xué)性、可信度。第二部分:電子護(hù)理文書(shū)實(shí)時(shí)質(zhì)控系統(tǒng)的實(shí)現(xiàn)。本課題研究前期,系統(tǒng)各功能模塊內(nèi)容已通過(guò)Delphi法確定,本研究旨再次對(duì)各功能模塊具體功能進(jìn)行專(zhuān)家訪談最終確定系統(tǒng)模塊功能,實(shí)現(xiàn)質(zhì)控系統(tǒng)的程序編寫(xiě)。研究者作為護(hù)理專(zhuān)家與軟件工程師的溝通橋梁,為軟件工程師提供系統(tǒng)功能模塊內(nèi)容,協(xié)助軟件工程師開(kāi)發(fā)系統(tǒng)程序。系統(tǒng)開(kāi)發(fā)完成后組織在臨床試運(yùn)行,運(yùn)行過(guò)程中不斷收集系統(tǒng)應(yīng)用反饋建議,對(duì)系統(tǒng)功能進(jìn)行修改完善,以PDCA循環(huán)方法持續(xù)優(yōu)化系統(tǒng)功能。結(jié)果:(1)確定了電子護(hù)理文書(shū)質(zhì)控指標(biāo)體系,包括一級(jí)指標(biāo)2項(xiàng),二級(jí)指標(biāo)14項(xiàng),三級(jí)指標(biāo)103項(xiàng),兩輪專(zhuān)家咨詢(xún)中,專(zhuān)家的積極系數(shù)均為100%,權(quán)威系數(shù)為0.96,2輪咨詢(xún)結(jié)果中三級(jí)指標(biāo)的和諧系數(shù)值分別為0.340和0.381,經(jīng)卡方檢驗(yàn)P值均小于0.01。(2)電子護(hù)理文書(shū)實(shí)時(shí)質(zhì)控系統(tǒng)初步形成,包括病歷調(diào)閱模塊、信息反饋模塊、信息反饋?zhàn)值淠K、質(zhì)控問(wèn)題統(tǒng)計(jì)分析模塊。系統(tǒng)在臨床科室試應(yīng)用期間收集和解決問(wèn)題共5項(xiàng)。結(jié)論:電子護(hù)理文書(shū)質(zhì)控指標(biāo)體系包括2項(xiàng)一級(jí)指標(biāo),14項(xiàng)二級(jí)指標(biāo),103項(xiàng)三級(jí)指標(biāo),可為信息化質(zhì)控電子護(hù)理文書(shū)質(zhì)量提供量化、客觀、科學(xué)的檢查標(biāo)準(zhǔn);電子護(hù)理文書(shū)實(shí)時(shí)質(zhì)控系統(tǒng)主要包括病歷調(diào)閱模塊、信息反饋模塊、信息反饋?zhàn)值淠K、質(zhì)控問(wèn)題統(tǒng)計(jì)分析模塊,可對(duì)電子護(hù)理文書(shū)書(shū)寫(xiě)質(zhì)量進(jìn)行實(shí)時(shí)監(jiān)控、對(duì)質(zhì)控?cái)?shù)據(jù)及時(shí)反饋、存儲(chǔ)和統(tǒng)計(jì)分析,為提高電子護(hù)理文書(shū)質(zhì)控效率和信息化管理水平提供了有力檢查工具。
[Abstract]:Objective: to develop the real-time quality control system of electronic nursing documents, to realize the automatic monitoring of the contents of the electronic nursing documents, and to carry out the manual monitoring based on the quality control system, and to give real-time feedback to the monitoring results. Storage, statistics and analysis, improve quality control efficiency, quality control means and quality management level of electronic nursing documents. At the same time, an electronic nursing document quality control index system was constructed to provide an objective and scientific evaluation standard for the examination of electronic nursing document based on quality control system and quantitative evaluation of the quality of electronic nursing document. Methods: this study is divided into two parts. Part one: research on quality control index system of electronic nursing documents. On the basis of consulting a large number of related documents, books and expert interviews, the quality control index system of electronic nursing documents was preliminarily worked out. The quality control index system of electronic nursing documents was preliminarily drawn up. 18 experts from hospital management, nursing management and clinical nursing were consulted twice by Delphi method, and the consultation data were statistically analyzed by using the software of SPSS 17.0. The index selection followed the principle of importance assignment 鈮，

本文編號(hào)：2088866