电子护理病历与手工护理病历优势比较的研究  

Research on electronic nursing records versus manual nursing records

作　　者：李惠卿[1] 赵德生[1] 汤舜銮[1] 林瑄[1] 洪蝶玫[1] 

机构地区：[1]汕头市中心医院,515031

出　　处：《国际医药卫生导报》2012年第23期3394-3396,共3页International Medicine and Health Guidance News

基　　金：汕头市重点科技计划项目立项课题（汕府科[2011]46号42-39）

摘　　要：目的比较电子护理病历与手工护理病历的不同书写方式，从中找出两者的差异。方法采用临床调查的方式。2010年8月1-30日手工护理病历2031份，平均住院67．7人／天，为A组；2012年8月1—30日电子护理病历2132份，平均住院71人／天，为B组。调查体温表绘制、医嘱处理、护理记录书写速度、质量。手工护理病历与电子护理病历书写格式相同。结果A组、B组体温表绘制耗时比较，A组：（82．93±1．92）批量，天（vain），（1．23±0．02）min／份；B组：（14．97±0．46）批量／天（min），（0．21±0．00）mird份；，值分别为70．23与120．82，P均〈0．05。A组、B组医嘱处理耗时比较，A组：（187．93±5．89）批量／天（rain），（2．78±0．05）min／份；B组：（80．67±3．05）批量／天（min），（1．13±0．04）min／份；f值分别为33．08与54．72，JD均〈0．05。A组、B组书写耗时比较，首次护理记录单：A组（10．10±0．47）min，B组（2．85±0．21）min，f值为28．24，P〈0．05；护理记录单：A组（4．99±0．54）min／次，B组（1．72±0．23）min／次，值为11．13，P〈0．05。结论电子病历改变工作流程和方式，不仅提高工作效率和质量，还便于检索、查阅和管理护理病历。Objective To explore the different way of writing between electronic nursing records and manual nursing records and find out the difference between those two. Methods A clinical survey was conducted. 2031 pieces of manual nursing records created between August 1st and August 30th, 2010 were used as group A, with an average hospitalization of 67.7 patients/day. 2132 pieces of electronic nursing records created between August 1st and August 30th, 2012 were used as group B, with an average hospital- ization of 71 patients/day. Body temperature chart, medical order, and speed and quality of nursing record writing were investigated. The format of electronic nursing records was the same as that of manual nursing records. Results Group B spent much less time in body temperature chart drawing （ [14.97 ± 0.46] batches/d [mini, [0.21±＋ 0.00] rain/piece vs. [82.93±1.92] batches/d [mini, [1.23 ± 0.02] rain/piece; t=70.23, 120.82, P〈 0.05）, conduction of medical order （ [80.67 ± 3.05] batches/d [mini, [1.13±0.04] rain/piece vs. [187.93± 5.89] batches/d [mini, [2.78 ± 0.05] rain/piece; t=33.08, 54.72, P〈 0.05）, and nursing record writing （ [2.85±0.21] rain/piece, [l.72 ±0.23] rain/piece vs. [10.10± 0.47] min/piece, [4.99± 0.54] rain/piece; t=28.2d, 11.13, P〈 0.05） than group A. Conclusions Electronic medical records alter the process and methods of nursing care and improve work efficiency and quality, which is easier to retrieve, consult, and manage the nursing records.

关 键 词：手工护理病历 电子护理病历 工作效率 

分 类 号：R47[医药卫生—护理学]