个性化电子护理记录单在重症监护室的应用与实践  

Application and Practice of Personalized Electronic Nursing Record Sheet in ICU

作　　者：吴玲玲 张方[1] 肖辉[1] WU Lingling;ZHANG Fang;XIAO Hui(Zhognan Hospital of Wuhan University,Wuhan 430071,Hubei,China)

机构地区：[1]武汉大学中南医院信息中心,湖北省武汉市430071

出　　处：《中国卫生信息管理杂志》2020年第2期207-210,共4页Chinese Journal of Health Informatics and Management

摘　　要：目的提升重症监护室(ICU)信息化管理水平,加强临床护理人员对重症患者的个性化护理服务.方法根据重症患者病情的不同,在ICU护理记录单(科室模板)基础上添加一些个性化护理模块或者项目(个人模板),有针对性地改善重症患者的护理服务质量.结果个性化电子护理记录单上线,提高了床边护理质量.结论应逐步推广ICU个性化电子护理记录单,完善重症监护信息系统,对后期数据提取及科研有很大的益处.Objective To improve the ICU information management and enhance the clinical nurses'personal care services for critically ill patients.Methods According to the different conditions of critically ill patients,some personalized nursing modules or projects(personal template)are added on the basis of the ICU nursing records sheet(department template)to improve the quality of nursing services for critically ill patients.Results Personalized electronic nursing records are run on-line to improve the quality of bedside care.Conclusion The ICU personalized electronic nursing record sheet should be gradually promoted to improve theinformation system of intensive care,which will greatly benefit the later data extraction and scientific research.

关 键 词：重症监护室 个性化 护理服务质量 科研 

分 类 号：R-058[医药卫生] R47-05