定位二维码识别技术在急性脑卒中患者护理记录书写中的应用  

Application of positioning two-dimensional code recognition technology in writing nursing records of patients with acute ischemic stroke

作　　者：邓亚银 李白玉 李柯叶 牛荣 黄少玲 张珠凤[1] Deng Yayin;Li Baiyu;Li Keye;Niu Rong;Huang Shaolin;Zhang Zhufeng(Department of Emergency,Zhejiang Hospital,Hangzhou 310000,Zhejiang,China)

机构地区：[1]浙江医院急诊科,浙江杭州310000

出　　处：《中国中西医结合急救杂志》2023年第6期725-729,共5页Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care

基　　金：浙江省医药卫生科技计划项目(2023KY448)。

摘　　要：目的将个人数字助理(PDA)扫描定位二维码识别技术应用于缺血性脑卒中静脉溶栓患者中进行护理记录书写,并评价其应用效果.方法采用类实验性研究方法,以浙江医院2021年9月至2022年2月采用移动护理车进行常规护理书写的58例急诊缺血性脑卒中静脉溶栓患者的护理记录作为对照组,以2022年3月至8月应用PDA扫描定位二维码进行护理书写的51例急性缺血性脑卒中静脉溶栓患者护理记录作为观察组.比较两组脑卒中静脉溶栓患者护理记录书写所需用时、护理记录书写错误发生率的差异,并评估急诊护士对PDA扫描定位二维码进行护理记录书写的满意度.结果观察组采用PDA扫描定位二维码进行护理记录书写时间较对照组明显缩短[s:137(109,192)比480(436,604),P<0.05],首程专科评估内容有欠缺率[3.92%(2/51)比20.69%(12/58)]、溶栓观察内容不够详细出现率[7.84%(4/51)比43.10%(25/58)]均较对照明显降低(均P<0.05).观察组和对照组溶栓药物泵入记录不规范率[0%(0/51)比1.72%(1/58)]、肌力评估记录不规范率[1.96%(1/51)比5.17%(3/58)]、错别字出现率[0%(0/51)比3.44%(2/58)]比较差异均无统计学意义(均P>0.05).此外,急诊护士对PDA扫描定位二维码识别技术进行护理记录书写的整体满意度为92.94%(2844/3060),对定位二维码辅助同步护理记录各条目平均得分均>4.5分,其中对易于操作的满意度得分最高为(4.78±0.50)分,护士对PDA扫描定位二维码进行护理病历书写接受度好,能够满足临床需求.结论采用PDA扫描定位二维码辅助脑卒中治疗流程中护理记录的书写能有效缩短书写护理记录用时,减少护理记录错误的发生率,提高护理病历质量;同时能有效降低护士在静脉溶栓流程中的书写负担,提高护士对护理记录的满意度,值得临床推广.Objective To apply the personal digital assistant(PDA)scanning positioning two-dimensional code recognition technology in writing nursing records in patients with acute ischemic stroke treated with intravenous thrombolysis,and to evaluate the application effect.Methods The quasi-experimental design was conducted.The nursing records routinely written by emergency nurses using mobile nursing cart for 58 patients with acute ischemic stroke treated with intravenous thrombolysis admitted to department of emergency of Zhejiang Hospital from September 2021 to February 2022 was taken as the control group,and the nursing records written by emergency nurses using PDA for 51 patients with acute ischemic stroke treated with intravenous thrombolysis from March 2022 to August 2022 through scanning positioning two-dimensional code recognition technology was used as the observation group.The differences of time required for writing nursing records and the incidence of errors in nursing records were compared between the two groups,and the satisfaction of emergency nurses in the observation group using PDA scanning positioning two-dimensional code to write nursing records was evaluated.ResultsThe time required for writing nursing records in the observation group was significantly shorter than that in the control group[seconds:137(109,192)vs.480(436,604),P<0.05],the incidence of inadequate records of the first course of specialist assessment[3.92%(2/51)vs.20.69%(12/58)],and the incidence of insufficiently detailed records of thrombolytic observations[7.84%(4/51)vs.43.10%(25/58)]were significantly lower than the control group(both P<0.05).The differences between the observation group and the control group were not statistically significant when comparing the incidence of rregularities in thrombolytic drug pump records[0%(0/51)vs.1.72%(1/58)],incidence of irregularities in muscle strength assessment records[1.96%(1/51)vs.5.17%(3/58)],and the occurrence of typos in the nursing records[0%(0/51)vs.3.44%(2/58),all P>0.05].In addition,the

关 键 词：定位二维码 二维码识别 护理记录书写 急性脑卒中 满意度 

分 类 号：R743.3[医药卫生—神经病学与精神病学]