基于PDA的电子特护记录单的应用探讨  

The application of electronic record single care based on PDA

作　　者：罗晓华[1] 李睿[1] 郑艺君 

机构地区：[1]解放军第一七五医院厦门大学附属东南医院,福建漳州363000

出　　处：《医疗装备》2016年第3期196-197,共2页Medical Equipment

摘　　要：目的探讨基于PDA的电子特护记录单的运用。方法自2013年6月至2014年1月,在肿瘤血液科选取工作量相当的两个病区,分别使用传统纸质手写特护记录单和基于PDA的电子特护记录单,对使用情况进行对比分析。结果基于PDA的电子特护记录单减少了手抄特护记录单因错误而多次返工的现象,方便后台随时调取临床信息,有利于护理管理者进行实时质控,同时可实现床边记录,记录更加真实、准确,大大减少了护士工作量,提高了护士工作效率,缩短了出院病历归档时间,提高了护理文书质量,达到了患者、医师、护理管理者、护士四方满意。结论基于PDA的电子特护记录单方便了护理工作,深受临床欢迎,应大力推广使用。Objective aiming at traditional paper written in clinical nursing care records the problems existing in the single use, discusses the use of electronic record single care based on PDA, Methods from June 2013 to January 2014. the two heaw workload in the seledion of tumor onset ward, respectively, using traditional paper written records list and care based on PDA eledronic record sheet, care of usage were analyzed. Results based on PDA electronic records care reduces the hand-written intensive care record sheet for errors and rework phenomenon for many times, convenient background clinical information to be obtained at any time, real-time quality control for nursing managers, at the same time can be realized by the bed record, record more realistic and accurate, and greatly reduce the workload of nurses, improve the working efficiency of nurses, shortens the time of discharged patients medical records archive and improve the quality of nursing documents, to the patients, doctors, nursing administrators, nurses the quartet. Conclusion based on PDA electronic record unilaterally modern nursing care, are very popular with clinical, should be vigorously promote the use.

关 键 词：肿瘤内科 PDA 电子特护记录单 

分 类 号：R472[医药卫生—护理学]