危重病电子护理记录单的应用与效果  

Application and effect of electronic nursing records of critical patients

作　　者：朱永健[1] 宋振兰[1] 殷少华[1] 王猛[2] 闫赟[1] 徐卫星[3] 徐培国[3] 

机构地区：[1]山东省烟台毓璜顶医院护理部,264000 [2]山东省烟台毓璜顶医院胃肠外一科,264000 [3]山东省烟台毓璜顶医院计算机中心,264000

出　　处：《中华现代护理杂志》2011年第30期3685-3687,共3页Chinese Journal of Modern Nursing

摘　　要：目的探讨危重病电子护理记录单的应用及效果。方法分析比较危重病电子护理记录单应用前后书写时间、书写中存在的问题，评价其应用效果。结果手工书写24h危重护理记录所需时间平均为（63．65±4．50）min，使用电子护理记录单后所需时间平均为（33．40±3．10）min，两组比较差异具有统计学意义（t=24．76，P〈0．01），危重病电子护理记录单的应用明显减少了护理人员用于书写文书的时间；在保证记录的整体效果、及时性、准确性、规范性等方面优于手工护理记录，差异均有统计学意义（P〈0．01）。程序中质控点的设定方便护理文书的检查、质控。结论危重病电子护理记录单的使用提高了护理人员的工作效率，提高了护理质量，保障了患者的安全。Objective To explore the application and effect of electronic nursing records of critical patients. Methods Analyze and compare the time before and after the application of electronic nursing records. Analyze the problems in writing and evaluate the application results. Results The time for hand records for 24 h critical nursing was （ 63.65 ± 4.50） min and （ 33.40 v3.10） min for electronic record, and the differences between them were statistically significant （t = 24. 76, P 〈 0. 01 ）. Electronic record is better than hand record in ensuring the overall effectiveness, timeliness, accuracy, specifications and other aspects （P 〈 0. 01 ）. The check and quality control of nursing instruments become more convenient because of the design of quality control points. Conclusions The application of electronic nursing records can effectively improve the quality and efficiency of nursing work, as well as ensure patient＇ s safety.

关 键 词：危重病 电子护理记录单 效果 质量控制 

分 类 号：R47[医药卫生—护理学]