應用動態表單建構護理紀錄資訊系統

Applying Dynamic Forms to Construct the Nursing record System

護理紀錄是護理人員記載病患在某一段時間內所接受的護理過程，包含護理觀察、診斷治療、照護活動及接受措施後的反應等的事實描述。運用表單方式記載護理紀錄，優點是可以統一護理紀錄書寫格式、方便溝通與提昇記錄效率，提供連續照護的參考。本文旨在提出以詞彙、意義、構句及段落所組成的動態表單機制，建構一實務上兼顧護理過程具體可行的護理紀錄資訊系統，包含護理問題紀錄及敘述性護理紀錄，以取代傳統的紙本式書寫。本文所提出的動態表單結構除了產出電子化的純文字護理紀錄報告外，期望電子化護理照護計劃的資料，對未來個案教學、臨床路徑與護理知識建構及行政決策的應用有所幫助。除此之外，詞彙、意義的產出將是後續資訊萃取的重要基礎。

The nursing record is a way for nurses to capture information regarding the nursing process of a particular patient during a given time period. The information captured includes nursing observation, diagnosis and treatment, nursing care and the response to that care, and descriptions of other related facts. The advantages of utilizing a form-based approach to create nursing care plan is that a unified format is convenient for communication, improving data collecting process, and it can also be used as a guideline for nursing care. In our paper, we proposed that a structured dynamic form is composed of terminology, patient information, sentence and paragraph, and utilize these structured dynamic forms for the construction of a Nursing record System. The main purpose of our research is to construct a practical Nursing Record System which will be accommodating of sensitive to the actual nursing practice, and in the process replace the traditional paper-based nursing records with one which can be stored electronically. The dynamic form-based framework described in this paper, in addition to being able produce automatically a purely text-based nursing record entry, can be used in the future to perform the following tasks as well: research related to electronic case study, the mining of clinical path, nursing decision support, constructing nursing knowledge; and the structured terminology and meaning will be an important foundation for extracting information from nursing records.