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Sunday, 30 October 2011: 3:25 PM
Learning Objective 1: Through decision support technology to know about the nurses of decision marking on nursing care plan.
Learning Objective 2: The participant were all of nurses. We will be realize the utilization of care plan.
Background: The implementation of electronic medical records has become a mainstream information technology development around the world, than in foreign countries, hospitals in Taiwan information technology resources in the care plan decision-making considerably less. Objective: To explore the information technology decision support system for care plan usage. Methods: a retrospective study, the database of nursing information systems acquisition, subjects were self-care theory Orem's eleven systems and revised version of the NANDA nursing care plan 63. During the study period from January 1, 2008 to December 10, 2010, to SPSS 13.0 for Windows descriptive statistical analysis. Results: In the past three years, based on Orem's self care theory nursing assessment, the first automatically generated using decision resources are the common system of water (140820/493885, 29%); medication history of (87377/493885 17% ); Medication compliance (79332/493885, 16%); active and rest (46934/493885, 10%). Then generated by the nursing staff to determine the top three in order were water (7756/10455, 74%); air (1239/10455, 12%); activities and rest (775/10455, 7%). Finally, the system generated by the care plan are the first water system is a potential risk of infection, accounting for 84% (6507/7756); air system was ineffective airway clearance, accounting for 72% (890/1239); activities and rest system was the potential risk of injury - falls, accounting for 87% (672/775). Conclusions: Recommended as a teaching nursing students or new staff to set the use of patient health problems; nursing research to establish the first empirical guidelines for chest care; clinical practice, thoracic localization construction plan and clinical pathway of care based on patient classification reference.