中医护理结构化电子病历系统的应用与分析  

Application and analysis of Electronic Medical Record system of nursing care of Traditional Chinese Medicine

作　　者：周姣媚[1] 张素秋[1] 樊艳美 刘新影 陈丽丽[1] ZHOU Jiaomei;ZHANG Suqiu;FAN Yanmei;LIU Xinying;CHEN Lili(Nursing Department,Guang'anmen Hospital,China Academy of Chinese Medical Sciences,Beijing,100053,China)

机构地区：[1]中国中医科学院广安门医院护理部,北京市100053 [2]中国中医科学院广安门医院风湿,北京市100053 [3]中国中医科学院广安门医院泌尿科,北京市100053

出　　处：《中国护理管理》2019年第10期1441-1444,共4页Chinese Nursing Management

基　　金：北京中医药科技发展资金项目(JJ2018-69)

摘　　要：目的:评价中医护理结构化电子病历系统的应用效果。方法:采集2018年10月至2019年6月我院风湿科病房第一诊断为“尪痹”的211例患者的数据,从辨证分型、临床常见症状、中医护理技术应用情况等角度进行分析。结果:结构化电子病历系统的应用利于数据的规范、完整及客观采集,为中医护理方案的优化提供数据支持。结论:结构化电子病历系统的应用促进了中医护理方案的有效落实,为方案的优化提供了依据,提升中医护理服务质量。Objective: To evaluate the effect of the structured Electronic Medical Record system on optimization of nursing care planning in application of Traditional Chinese Medicine (TCM). Methods: Information on syndrome differentiation, clinical symptoms and applied TCM techniques were collected and analyzed among 211 patients who were admitted to the rheumatology unit and diagnosed with "Wangbi", between October 2018 and June 2019. Results: The use of structured Electronic Medical Record system is conducive to the standardization, integration and objective collection of patient's data, therefore provides adequate data support for the optimization of nursing care planning in applying TCM. Conclusion: The use of structured Electronic Medical Record system promotes the effectiveness of implementation of nursing care plans, provides the best evidence for optimization of nursing care planning, and improves quality of care in applying TCM among patients.

关 键 词：中医 护理方案 尪痹 类风湿性关节炎 电子病历 优化 

分 类 号：R47[医药卫生—护理学]