电子护理文书在临床护理工作中的应用  

作　　者：林少虹[1] 罗少红[1] 黄艳红[1] 

机构地区：[1]南方医科大学附属东莞石龙人民医院,广东东莞523326

出　　处：《现代临床护理》2010年第12期60-61,共2页Modern Clinical Nursing

摘　　要：目的探讨电子护理文书在临床护理工作中的应用效果。方法设制通用护理单和专科护理单等23块电子表格模块,为护士提供护理文书工作的平台;选择试点科室,试用3个月后,认为可行,在全院全面推广使用。结果电子护理文书记录所需时间较手写护理文书短,两者比较,均P<0.001,差异具有统计学意义。采用电子护理文书使护理文书达到规范化、标准化、制度化。结论电子护理文书的应用,缩短了护理文书书写时间,让护士有更多的时间为病人服务;使护理文书达到规范化、标准化、制度化,提高了护理工作质量和效率。Objective To study the effect of electronic nursing documents in clinical nursing practice.Methods 23 electronic form sets related to general nursing and special nursing forms were designed to establish a platform for nursing documentation.The clinical departments were selected for the trial and verified 3 months after trial and then generalized all through the hospital.Results The time for electronic nursing documentation was significantly shorter than documentation by hand writing（P 0.001）.The hospital nursing documentation was standardized and systematized.Conclusions The application of electronic nursing documentation shortens the time for nursing documents,allowing nurses to have more time for service.Meanwhile it realizes standardization and systematization of nursing documentation so that the nursing efficiency is increased.

关 键 词：电子护理文书 信息系统 护理 工作效率 

分 类 号：R47[医药卫生—护理学]