IMPROVING THE QUALITY OF INFORMATIZATION OF NURSING RECORDS FOR WOUND ASSESSMENT AND CARE FOR NURSING STAFF

Introduction: Wound care is the most common nursing activity performed by nurses. The study pointed out that with the continuous construction of various operations in the medical information system, it is easy to create a situation of repeated creation or input of information in the form of multiple forms. It is recommended to integrate the clinical process in a timely manner. Only when the system is horizontally integrated can the benefits of the system assisting clinical operations be maintained.

Nursing information system of our hospital - Wound assessment and care records are implemented on 4 pages respectively (Physical Assessment, Recording and Valuation, Health Issues, Pressure Injury Reporting). The size of the area, the color and amount of secretions, and nursing measures) are all written repeatedly; the wound operation pages are built one after another, and 32% of the structured content is different, and multiple wound records are supplemented by description. 4.7 minutes were spent on wound records of nurses, the completeness of wound assessment and records was 83.2%, and the consistency was 78.4%.

Methods: Using ECRS (Eliminate、Combine、Rearrange、Simplify) analysis process, delete actions that can be simplified, merge or rearrange repetitive and time-consuming processes: 1.Eliminate: Eliminates manual entry of wound care data, and automatically completes the pressure injury report And automatically calculate the size of the wound and complete the valuation.2.Combine: Wound records are consolidated, using a visual humanoid map, which shows the location and type of wounds, and files and records are created on a unified page. 3.Rearrange: Fix structured content. 4.Simplify: Diverse forms, horizontal integration and application of data, automatically bring the archived data into health problems.

AIM:Wound records are complete and consistent up to 100%；The completeness and consistency of wound valuation reaches 100%；100% completeness of pressure injury report

 Results: The completeness of wound assessment and recording increased from 83.2% to 100% (↑16.8%) and the consistency increased from 78.4% to 100% (↑21.6%); the time spent on wound recording decreased from 4.7 minutes per time to 1.5 minutes per time (↓3.2 seconds), 3,248 hours/year.

 Conclusion: Through the integration, automation, optimization, innovation and other elements of system intelligence, the data between systems are horizontally interfaced and integrated, re-examined the process, simplified and eliminated unnecessary steps, provided the most important accuracy, accuracy and efficiency of the care process, and effectively improved The quality of professional care and the effectiveness of nursing staff.