一体化护士工作站护理评估单智能升级及应用  

Upgradation and Application of Nursing Assessment Sheet in Integrated Nurse Workstation

作　　者：王惠娟[1] 池小锋[2] 郭英俊[2] 魏淑霞[3] 薛晓英[2] WANG Hui-juan;CHI Xiao-feng;GUO Ying-jun(Nursing Department,the 251st Hospital of PLA,Zhangjiakou 075000,Hebei Province,P.R.C.)

机构地区：[1]解放军第251医院神经外科,河北省张家口市建国路13号075000 [2]解放军第251医院护理部,河北省张家口市建国路13号075000 [3]解放军第251医院肿瘤二科,河北省张家口市建国路13号075000

出　　处：《中国数字医学》2018年第12期96-97,100,共3页China Digital Medicine

摘　　要：目的:探讨一体化护士工作站护理评估单智能设计与应用效果。方法:通过细化护理评估项目、增加链接、列表点选等智能功能、修订护理评估工具、与PDA资源共享等升级,比较升级前后护理评估用时、评估准确性及完整性。结果:护理记录单升级前后评估用时、评估准确率及完整率方面差异具有统计学意义(P<0.05)。结论:智能升级后的护理评估单能有效减少护理评估用时,实现把护士还给病人的目标;能有效提升护理评估质量,实现护理病历规范书写,值得推广借鉴。Objective: To explore the upgradation and application of nursing assessment sheet in Integrated nurse workstation. Methods: We upgradated the nursing assessment sheet by refining nursing evaluation items, adding links, list click and other intelligent functions, revising nursing evaluation tools, sharing with PDA resources and so on. Compared the time spent, accuracy and completeness of nursing evaluation before and after upgradation. Results: There were significant differences in time spent, accuracy and completeness of nursing records before and after the upgrading(P<0.05). Conclusion: The nursing assessment sheet after intelligent upgrading can effectively reduce the time spent of nursing assessment and realize the goal of returning nurses to patients. It also can effectively improve the quality of nursing evaluation, to achieve standardized writing of nursing records, which worthy of promotion and reference.

关 键 词：一体化护士工作站 护理评估单 应用 

分 类 号：R319[医药卫生—基础医学]