目的:实现医护数据共享,护理病历标准化书写和结构化存储,满足不同临床科室的个性化需求,提高护理工作效率.方法:结合现有的HIS数据库平台,利用现有的结构化电子病历接口,采用现有软件开发工具进行开发.结果:实现了全院护理病历标准化书写以及护理病历的结构化存储,加快了护理数据的采集过程,做到了医护数据充分共享.结论:通过开发和应用该系统能明显提高护士工作质量与效率,满足各临床科室的个性化需求.%Objective: To realize the sharing of the medical data between the doctor and nurse and To write the nursing clinical record in a standard mode and To realize the structured storing of the nursing clinical record and To satisfy the characteristic requirement of different clinical department in order to promote the clinical nursing work efficiency. Methods: Using the current HIS database platform and using the current structured EMR interface and using the current software development tools. Results: The system was established in entire hospital. It realized the structured storing of the nursing clinical record and he nursing clinical record was writed in a standard mode. It improved the nursing data gathering. It also realized the sharing of the medical data between the doctor and nurse. Conclusion: The quality and efficiency was obviously promoted by developing and applying this system and it also satisfy the characteristic requirement of different clinical department.
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