护理全过程无纸化研发与实践  

Development and Practice of Paperless Nursing Process

作　　者：应波[1] 韩斌如[1] 梁志刚[1] 尉俊铮[1] 李嘉[1] Binru;LIANG Zhigang(Xuanwu Hospital Capital Medical University,Beijing,100053,China)

机构地区：[1]首都医科大学宣武医院,北京100053

出　　处：《中国卫生质量管理》2019年第1期15-18,共4页Chinese Health Quality Management

摘　　要：整合医嘱执行过程中多个系统产生的数据,全面取消纸质执行单,通过色标管理、核对执行与提醒拦截等完成在线患者身份确认与医嘱核对,实现重要护理执行过程同步写入护理病案。实施后,医护人员使用电子执行单体验得分高于使用纸质执行单得分(P<0.05),医嘱执行内容同步写入护理病案得分高于医嘱执行后手工录入得分(P<0.05),交班报告智能写入总用时较手工书写节约了55.13%。护理全过程无纸化是大数据再利用的有益尝试,提高了护理工作效率与质量。To integrate and utilize the data generated by multiple information systems in the implementation process of medical orders,completely cancel the paper execution order,complete online patient identification and medical checkup through color code management,check control execution and reminder interception,important nursing implementation process was synchronously written into the nursing case.After implementation,the medical staff used the electronic execution order experience score higher than the paper execution order score(P<0.05),the doctor's execution content synchronous writing medical record score was higher than the willing execution manual input score(P<0.05),the shift report intelligent writing saved 55.13%compared to manual writing.The paperless nursing process was a useful attempt to reuse big data,improving the efficiency and quality of nursing work.

关 键 词：无纸化护理 信息化 数据利用 医嘱执行 护理记录 

分 类 号：R197.324[医药卫生—卫生事业管理]