电子护理文书在临床护理工作中的应用  

Application of electronic nursing document to clinical nursing care

作　　者：叶衬笑 李见好[1] 

机构地区：[1]东莞市石龙人民医院,广东东莞523321

出　　处：《齐鲁护理杂志（下旬刊）》2011年第4期14-15,共2页Journal of Qilu 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:随机选取100份在临床护理工作中使用电子护理文书的护理记录(观察组)和100份使用手写护理文书的护理记录(对照组),对其护理记录中的书写质量、时间及相关存在问题进行统计分析、比较。结果:观察组在书写质量、书写时间等整体效果上均优于对照组(P<0.05,P<0.01)。结论:在临床护理工作中使用电子护理文书,其书写时间短、操作简单、速度快、质量高,对提高护理工作效率有重要意义。Objective： To explore the application effect of electronic nursing document in clinical nursing care. Methods： 100 pieces of clinical nursing records randomly selected from the electronic nursing documents were taken as observation group and another 100 pieces of handwritten nursing records were taken as control group. The quality of the two kinds of nursing re- cords, writing time and related problems were statistically analyzed and compared between the two groups. Results： The quality of nursing records, writing time and the overall effect were superior in the observation group to the control group （P〈0.05, P〈0.01）. Conclusion： The electronic nursing document applied to the clinical nursing care has the advantages of short writing time, simple operation and high quality of nursing records, which is important to improve the efficiency of nursing care.

关 键 词：电子护理文书 临床护理 护理记录 手写 质量 

分 类 号：R197.3[医药卫生—卫生事业管理]