Method for generating nursing record sheet

Abstract

The invention relates to a method for generating a nursing record sheet. The method comprises the steps of selecting a nursing record sheet template as required, and creating a nursing record sheet; performing automatic filling of input items, receiving user input to the input items, and presenting the input in the input items; inputting a strongly-related entry item at the first level; and when auser saves the nursing record sheet, generating an evaluation value based on the input items in the nursing record sheet. According to the method, through the structured nursing item template, the entry of the nursing record sheet is simplified, so that it is ensured that doctors timely know patients' conditions while nurses' manual entry workload is reduced, attention is paid to the patients' conditions at the first time, and related treatment is given. In addition, the structured nursing item content can be dynamically added with the development of the medical technology, to form the achieve of a knowledge base, and nurses can be helped to learn nursing points and treatment measures of nursing items, which helps the nurses to learn business knowledge and improve their work ability.

Description

【Technical field】 [0001] The invention belongs to the technical field of medical information, in particular to a method for generating a nursing record sheet. 【Background technique】 [0002] The daily work of clinical nurses is mainly divided into two parts: the execution of doctor's orders and the recording of nursing documents; and among the nursing documents, the nursing record sheet is the most recorded; there are two main ways to record the existing nursing record sheets: first, paper Manual copying of documents; Second, manual entry of electronic forms. These two methods have the following disadvantages: First, a large amount of handwriting or manual entry is time-consuming and laborious, and the heavy recording work takes up a lot of precious time of the nurses, and errors are prone to occur in the process of copying and entry; When recording, there is no certain reference knowledge, which is not conducive to the learning of nurses' professional knowledge and the imp...

AI Technical Summary

Problems solved by technology

These two methods have the following disadvantages: First, a large amount of handwriting or manual entry is time-consuming and laborious, and the heavy recording work takes up a lot of precious time of the nurses, and errors are prone to occur in the process of copying and entry; When recording, there is no certain reference knowledge, which is not conducive to the learning of nurses' professional knowledge and the improvement of work ability; third, it is not convenient for doctors to know the changes of patients' condition in time; based on the above problems, a new nursing record is urgently needed The bill generation method can simplify the entry of nursing record sheets through structured nursing item templates, so as to reduce the manual input workload of nurses and ensure that doctors can be informed of patients' conditions in a timely manner, pay attention to patients' conditions at the first time, and provide relevant treatment; In addition, the content of structured nursing items can dynamically increase with the development of medical technology, thereby forming the role of a knowledge base, which can help nurses learn the nursing points and treatment measures of nursing items, and help nurses learn professional knowledge and improve their working ability. promote

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