护理电子病历临床应用问题分析与对策建议  

Clinical Application of Nursing Electronic Medical Records: Problem Analysis and Countermeasures

作　　者：刘素温[1] 黄先涛[1] 南茹[1] 

机构地区：[1]河北北方学院附属第一医院,河北张家口075000

出　　处：《中国卫生质量管理》2014年第5期55-57,共3页Chinese Health Quality Management

摘　　要：目的 探讨护理电子病历临床应用中存在的问题及对策,提高护理电子病历质量.方法 选择2012年8月～12月住院1周以上患者病历,采用随机抽样法抽取500份护理电子病历,同时向临床一线护士发放调查问卷200份,收回200份.分析护理电子病历应用中存在的问题.结果 调查问卷结果显示,护理人员对护理电子病历的应用满意率为90.25％;抽查病历结果显示,存在问题主要是护理记录表达不准确、记录内容不连贯、真实性降低、内容不客观等,其中护理记录表达不准确比例（45.81％）明显高于其它问题,差异具有统计学意义（F=6.45,P＜0.05）.结论 护理电子病历的实施能够显著提高护理人员工作效率和满意度,但在实际应用中仍存在问题和不足,医院需采取积极的应对措施提高护理人员法制观念和护理电子病历质量,保证病历连贯性、真实性和客观性.Objective To explore the problems and countermeasures in the clinical application of electronic medical records,to improve the quality of nursing electronic medical records.Method The records of hospitalized patients with more than one week of length of stay from August to December 2012 were selected,of which 500 nursing electronic medical records were randomly selected.A total of 200 questionnaire on nursing electronic medical records were distributed among clinical nurse,and all were responded.The problems in application of nursing electronic medical records were analyzed.Result According to the results of the questionnaire survey,nursing staff satisfaction rate was 90.25％.the spot check showed that the problems were mainly inaccurate nursing records,inconsistency of the content,low authenticity,no enough objective of content,etc.,of which,the proportion of nursing record inaccurate （45.81％） was significantly higher than other problems （F =6.45,P ＜ 0.05）.Conclusion The implementation of the nursing electronic medical records can significantly improve the efficiency of nursing work and satisfaction,but there are still some problems and the insufficiency in practical application.The hospital should take active avoiding measures to improve the legal idea and electronic medical record level of nursing personnel to ensure medical record continuity,authenticity and objectivity.

关 键 词：护理电子病历 临床 应用 

分 类 号：R197.323[医药卫生—卫生事业管理]