护理文件信息系统的设计与应用效果  

Design and application of electronic nursing records system

作　　者：关欣[1] 王蕾[1] 聂圣肖[1] 冷婧[1] 戴雪松[1] 

机构地区：[1]北京医院护理部国家老年医学中心,北京100730

出　　处：《中华现代护理杂志》2017年第25期3305-3308,共4页Chinese Journal of Modern Nursing

摘　　要：目的 探讨护理文件信息系统的设计方案及临床应用效果.方法 结合临床实际设计出具有资源共享与导入、护理文件录入、质量控制与字典管理功能的护理文件信息系统,并在全院实施.统计实施后2014—2016年护理文件合格率、高危人群跌倒、压疮发生率和患者满意度,评价其应用效果.结果 护理文件信息系统实施后护理文件合格率从96.37%上升至97.98%;高危人群中跌倒发生率从0.35%下降至0.08%,高危人群中压疮的发生率从3.64%下降至2.85%;患者满意度从93.90%上升至96.53%.结论 护理文件信息系统节约书写时间,规范护理记录,提高了护理文件的合格率;同时还减少了护理不良事件的发生率,提高了患者满意度.但也存在着一些问题,需要进一步完善.Objective To discuss the design and application effects of the electronic nursing records system.Methods The electronic nursing records system with comprehensive functions including resource sharing and importing, nursing documents typing in, quality control and dictionary management, was designed based on the clinic and implemented in the hospital. Qualification rates of nursing documents, incidences of fall and pressure ulcer in high-risk population, and patient＇s satisfaction after the implementation from 2014 to 2016 were collected to evaluate the application effect.Results Qualification rate of nursing documents increased from 96.37% to 97.98%; incidence of fall in high-risk population decreased from 0.35% to 0.08%; incidence of pressure ulcer in high-risk population decreased from 3.64% to 2.85%; and patient＇s satisfaction increased from 93.90% to 96.53%.Conclusions The electronic nursing records system not only saves the writing time, standardizes nursing records, increases the qualification rate of nursing documents, but also can decrease the incidence of nursing adverse events and increase the patient＇s satisfaction. However, there are still some defects in the system that require the improvement.

关 键 词：不良事件 护理文件信息系统 质量管理 患者满意度 

分 类 号：R47[医药卫生—护理学]