中医整体护理电子病历系统的创建与应用  

Establishment and Application of Electronic Nursing Record System for Holistic Nursing Care in Chinese Traditional Medicine

作　　者：张广清[1] 刘玉珍[1] 王影[2] 雷丽芳[1] 丁美祝[1] 黎少霞[1] 叶凤梅[1] 李小华[3] 

机构地区：[1]广东省中医院护理部,广东广州510120 [2]广东省中医院针灸科,广东广州510120 [3]广东省中医院信息科,广东广州510120

出　　处：《护理学杂志》2005年第4期12-14,共3页

基　　金：2001年广东省科技计划项目(重大专项及重点项目;B306)

摘　　要：目的简化、规范中医护理工作程序,提高护理水平。方法根据中医院患者的特点建立包含6个模块(体温 单、入院评估、住院评估、护理记录、健康教育及出院指导)的中医整体护理电子病历,将神经内科等8个病区96名 护士随机分为电子病历组和常规书写组。电子病历组采用中医整体护理电子病历系统进行护理文件书写;常规书 写组采用常规方法书写护理文件。结果电子病历组病历书写、体温单记录时间显著短于常规书写组(均P< 0.01);护理诊断符合率显著高于常规书写组(P<0.01)。结论中医整体护理电子病历系统简化、规范了护理工作 程序,提高了工作效率与管理水平。Objective To simplify and standardize the working procedures of nursing care in Chinese Traditional Medicine (CTM) and improve the quality of nursing care.Methods An electronic nursing record system involving 6 modules was devised on the basis of characteristics of patients in CTM hospitals, with the modules covering the body-temperature sheets, evaluation at admittance, evaluation during hospital stay, nursing records, health education and guidance at discharge. ninty-six nurses at 8 ward areas of the Department of Neurosurgery of a hospital were divided into a group of electronic record (ER group) and a group of regular record (RR group). The nurses in the ER group used the electronic record system for the writing of nursing documents while nurses in the RR group employed regular methods. Results The time for writing medical records and body-temperature sheets in the ER group was significantly shorter than that of RR group(P<0.01,for all). The correct rate of nursing diagnosis was higher than that of the RR group(P<0.01). Conclusion The electronic nursing record system for the nursing care in CTM can simplify and standardize the nursing procedures and improve the working efficiency and quality of management.

关 键 词：中医院 电子病历 整体护理 工作效率 护理管理 

分 类 号：R47[医药卫生—护理学]