关键词: 导管护理；结构化；护理记录；智能辅助决策；数据质量

Abstract: Objective: To develop a structured catheter care documentation system integrated with intelligent decision support functions, aiming to enhance the standardization and accuracy of nursing records, improve the quality of nursing documentation, and increase the value of data utilization. Methods: A structured catheter care documentation knowledge base was built, encompassing the full management process of gastric tubes, urinary catheters, central venous catheters, peripherally inserted central catheters, and endotracheal tubes. The system was implemented across 15 departments in a tertiary grade A hospital in Beijing from June to December 2024. Experts were invited to evaluate the system's content, and a survey was conducted to assess the system's usage rate, acceptability, and the detection accuracy of the unplanned extubation monitoring platform. Results: The average expert evaluation score for the objectivity, accuracy, standardization, and importance of catheter care documentation was 4.83±0.21. The system usage rate was 94.50%. In the system acceptability survey, the average score of all items was 4.39±0.75 or higher, with a satisfaction rate of 90%. The detection accuracy of the monitoring platform increased from 1.73% to 6.30%, with significant differences (P<0.05). Conclusion: Nurses show high acceptability of the structured catheter care documentation system. The system significantly improve the standardization and quality of nursing records, optimize decision support capabilities, and demonstrate good potential for broader application. It plays an important role in improving nursing quality.

Key words: catheter care; structured; nursing record; intelligent decision support; data quality