建構營養照護資訊系統

A Nutrition Care Information System

目的：依據完整營養照護流程，營養評估、營養診斷、營養介入、營養監測與評值的四個步驟，建構「營養照護資訊系統」 ，做為儲存完整的營養照護資料、評值營養照護及效益的工具，並可以成為醫療團隊溝通平台。方法： 「營養照護資訊系統」建構於醫院資訊系統（hospital information system, HIS），在考量營養照護流程及病歷記錄程序後分別設定四個頁面：營養風險評估、飲食問題評估、具體改善建議、追蹤記錄。營養師可以在每次衛教完成後，藉由「營養照護資訊系統」印出衛教單張提供病人個別化的建議。「營養照護資訊系統」檔案由院內營養師共同管理，其中具有各項業務分析統計報表，可以提供營養師每月的業務分析。結果與討論：「營養照護資訊系統」透過個案與營養照護資料登錄，可以列印病人照護資料，方便張貼於病歷，減少重複書寫；可以為病人即時的、個別的訂作衛教單張。系統中的統計分析功能，可作為評估相關作業品質依據。為了更能提供完整的營養醫療照護，此系統目前只用於營養諮詢門診，未來可以規劃完成住院病人營養照護部分，及與多科團隊照護系統的連結。結論：「 營養照護資訊系統」 ，確實簡化營養師作業及手寫病歷記錄，即時印製衛教資料，提升照護品質，且能快速完成業務分析報表，有效提升工作效益。

Objective: The purpose of this study is to establish a nutrition care information system which composes the idea of integrated nutrition care process (nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation) and constructed a convenience for electronic documentation, data storage, benefit evaluation and a platform for medical team member communication. Methods: Nutrition care information system was based on the hospital information system(HIS) and constructed into four pages: nutrition risk assessment, dietary assessments, and specific recommendations for improvement and follow-up which according to nutrition care process and medical record procedures. All the hospital dietitians were in-charge to co-management of these files. A print-out after nutrition counseling and a monthly statistical report of the business analysis could print from the system. Result and discussion: There could print patients’ care information out from the 'nutrition care information system' through the case and nutritional care data login and it might reduce duplication writing. An individualized nutrition education leaflets printed for patients from the system immediately. Statistical analysis of the system function could be used as basis for assessing the quality of related work. This system is currently used only for outpatient nutrition counseling. The future might provide for resident patients and link with multidisciplinary team care system. Conclusion: 'Nutrition care information system', does simplify the operation and handwritten medical records, instant printing of nutrition education to improve quality of care, business analysis reports and can quickly and effectively enhance the clinical dietitians’ work efficiency.