コンピュータ支援による看護過程・看護診断支援システムの構築と運用―第1報：オーダリングシステムの構築とその運用

Development and Use of a Computerized System to Support Nursing Process and Nursing Diagnosis (Report 1)

　臨床で看護診断・看護過程を具体的に展開するために，コンピュータ支援による「看護過程・看護診断支援システム」を構築し，受け持ち看護婦の責任で運用している．システムは病院情報システムのサブシステムである看護情報システムの一部を構成する．その目的は，①ケアの効果と効率の測定，②リスクマネジメント，③有効で効率的な看護介入や看護管理情報の抽出などである．特徴は，①患者・家族の状態，健康のとらえ方，満足度の評価，リスクの予測，②P＆Nによる看護診断，③医学診断と看護診断の相補的な診断体系，④受け持ち看護婦の行った看護量の測定と評価，⑤恒常的な看護カンファレンスの実施，などである．臨床で看護診断・看護過程を効果的に行うには，①看護業務の明確化と事務的業務や周辺業務の整理による環境整備，②看護ケアと患者情報に責任をもつ受け持ち看護制などが不可欠である．

　A computerized system was developed to facilitate nursing diagnosis and nursing process in clinical nursing practice. This system has been used on each primary nurse's own responsibility. In this article, the outline, purposes, characteristics and utilization of this system are described. This system is a portion of the nursing information system of the hospital information system. The purposes of development of this system are: (1) to assess the effectiveness and efficiency of patient care, (2) to manage risks appropriately. This system is used: (1) to assess the conditions, health-related conceptions and level of satisfaction of a patient and his/her family, (2) to predict risks related to a patient and the family, (3) to identify problems (P) and needs (N) related to nursing care, (4) to facilitate the development of diagnostic system between pathological diagnosis and the nursing diagnosis, (5) to monitor the nursing activity of the primary nurse, and (6) to facilitate regular nursing conferences. For efficient nursing diagnoses and nursing process in clinical practice, it is necessary to clearly define the original role and tasks of nurses, to simplify other jobs (i.e. the clerical and interface jobs) required of nurses, to develop a primary nursing system and to provide computerized support systems to nurses.