结构化护理病历的设计与应用  

Design and Application of Structured Nursing Medical Records

作　　者：仲晓伟[1] 陈蔚 周奕[1] 

机构地区：[1]常熟市第二人民医院,江苏省常熟市海虞南路68号215500 [2]上海金仕达卫宁软件股份有限公司

出　　处：《中国数字医学》2015年第3期58-60,共3页China Digital Medicine

基　　金：常熟市卫生局科技计划项目(编号:cswsz201405)~~

摘　　要：结构化护理病历是医院护理管理的基础。按照国家卫计委表格化护理文书的要求,将医嘱单、体温单、手术清点记录、护理记录单四种类型的表格按照各自的特点,进行结构化分析,并实现结构化保存。通过对结构化护理病历的应用,能提高临床护理工作效率与医院护理管理水平。Structured nursing medical record is the foundation of hospital nursing management.According to the Ministry of Health Care tabular instrument＇s request,medical orders paper,temperature paper,surgery inventory records,nursing records four types of forms in accordance with their own characteristics,structural analysis,and to achieve structural preservation.Through the application of a structured medical care can improve the efficiency of clinical care and hospital nursing management.

关 键 词：护理管理 移动护理 护理病历 结构化 设计应用 

分 类 号：R197.3[医药卫生—卫生事业管理]