| Objective: This project aims to develop electronic nursing documents with field characteristics suitable for wartime environments.Based on the nursing work system of field rescue institutions,the content framework of wartime nursing document system has been established,and electronic nursing documents in tabular format have been prepared according to the system.The template provides a certain theoretical basis for the next step to realize the informatization design of wartime nursing documents.The wartime medical document information system is applicable to field medical clinics,field hospitals,hospital ship medical teams,and other relatively independent rescue organizations.It is attached to the field medical center information system and is connected to the front-line electronic injury ticket information system.Transmit the wounded and sick information in paper form,and then transmit the information to the rear hospital.With a view to improving the efficiency of writing documents,reducing the workload of nurses,speeding up the transmission of medical treatment information for the wounded and sick among various levels of treatment institutions,improving the treatment rate,and quickly restoring the combat effectiveness of the army.Methods: An initial version of the questionnaire for the system of wartime medical documents and compile the document content was formulated with document analysis method and semi-structure expert interviews.Retrieve relevant literature and related books as far as possible in the database,and conduct semi-structured interviews with 10 mobile health service team personnel with first-line experience.After collating and collecting data,an expert inquiry form was initially formed after group discussion.For the sake of ensure that the questionnaire is scientific and strict,three experts who meet the inclusion criteria were randomly selected for pre-survey,and the questionnaire was modified and improved.In the end,15 experts from Anhui,Jiangsu,Fujian,and Zhejiang were selected according to the inclusion criteria,and Delphi method was used to construct medical document system in wartime.Analyze the general information of experts by descriptive analysis of frequency and composition ratio,analyze the enthusiasm and authority of experts,and determine the degree of coordination of expert opinions by the coefficient of variation,coordination coefficient,and consistency coefficient.Use the above indicators to scientifically verify the constructed system.According to the established system,expert opinions and group discussions,and in accordance with the principle of simple and quickly recording of wartime documents,the documents were deleted and integrated,and a dictionary template of medical documents and treatment measures for field rescue institutions in wartime was compiled.Results: 1.A wartime nursing document system was established,and the finally established indicator system included medical evacuation documents,nursing medical records,nursing execution orders,and registration statistics.There were 4 first-level indicators,9 second-level indicators,and 30 third-level indicators.The positive coefficients of the experts in the two rounds of consultation were 100% and 80%,and the expert authority coefficient was 0.81,indicating that the experts were highly motivated and authoritative.The coordination coefficient of the second round of consultation index scores was 0.272 ~ 0.428(P <0.05).2.Prepare 8 nursing document templates for field rescue institutions during wartime,including: nursing records for critically ill patients,nursing records for lightly wounded patients,pain care assessment sheets,classified registration records for injured patients,daily report of casualty movement,registration form of transfusion reaction,nursing error registration form,inventory of combat rescue materials.Conclusions: 1.It is scientific and reliable to construct the wartime nursing document system by means of literature review,brainstorming,interview and Delphi.2.The construction of nursing document system in wartime can provide a theoretical basis for compiling nursing documents and achieving the informatization of documents. |
