PDA技术在健康医学科护理记录中的应用效果观察  

Application Effect Observation of PDA Technology in Nursing Records of Health Medicine Department

作　　者：官会莲 郑艳晓 杨英 Guan Huilian;Zheng Yanxiao;Yang Ying(Department of Health Medicine,The Second Medical Center of the Chinese People's Liberation Army General Hospital,Beijing 100853,China;不详)

机构地区：[1]中国人民解放军总医院第二医学中心健康医学科,北京市100853 [2]中国人民解放军总医院第二医学中心老年医学科,北京市100853

出　　处：《中国病案》2024年第10期32-35,共4页Chinese Medical Record

摘　　要：目的结合临床实践经验,探讨PDA技术在健康医学科护理记录中的应用效果。方法某科于2022年10月1日开始实施PDA技术,采用信封法,随机选取2021年11月1日-2022年9月30日收治的450例住院患者护理记录单作为实施前组,选取2022年11月1日-2023年10月31日收治的450例住院患者护理记录单作为实施后组,比较实施前后护理记录单缺陷发生率,并比较护理记录书写质量评分,比较PDA技术实施前后护理人员对记录方式的满意程度。结果PDA技术实施后护理记录缺陷发生率0.89%低于实施前9.56%,差异有统计学意义(χ^(2)=34.145,P=0.000)。PDA技术实施后护理记录管理要求、体温单、医嘱单和综合要求评分均高于实施前,差异有统计学意义(t=12.525、10.752、15.058、11.854,P<0.05)。PDA技术实施后护理人员对记录方式满意度(100.00%)明显高于实施前(80.00%),差异有统计学意义(χ^(2)=9.778,P=0.008)。结论PDA技术可减少健康医学科护理记录缺陷发生率,提高书写质量,减少护理记录差错,护理人员满意度高,值得推广。Objective To explore the application effect of PDA technology in nursing records of health medicine department combined with clinical experience.Method A department began to implement PDA technology on October 1st,2022.Using envelope method,450 inpatient nursing records admitted from November 1st,2021 to September 30th,2022 were randomly selected as the pre-implementation group,and 450 inpatient nursing records admitted from November 1st,2022 to October 31st,2023 were selected as the data after the implementation of PDA technology,the incidence of single defect of nursing record was compared before and after implementation,and the nursing record writing quality score was compared,and the nursing staff's satisfaction with the recording method was compared before and after the implementation of PDA technology.Results The incidence of nursing record defects after PDA was 0.89%lower than 9.56%before PDA,the difference was statistically significant(χ^(2)=34.145,P=0.000).After the implementation of PDA technology,the scores of nursing record management requirements,body temperature list,medical order list and comprehensive requirements were higher than those before the implementation,and the differences were statistically significant(t=12.525,10.752,15.058,11.854,P<0.05).After the implementation of PDA technology,nurses'satisfaction with the recording method(100.00%)was significantly higher than that before the implementation(80.00%),and the difference was statistically significant(χ^(2)=9.778,P=0.008).Conclusions PDA technology could reduce the incidence of nursing record defects,improve the quality of writing,reduce nursing record errors,nursing staff satisfaction was high and worth popularizing.

关 键 词：PDA技术 健康医学科 护理记录 应用效果 

分 类 号：R47[医药卫生—护理学]