信息化管理在儿科手术室护理文书中的应用  

Application of Information Management in Nursing Documents of Pediatric Operating Room

作　　者：杨雪[1] 张钰[1] 白雪梅[1] 赵荃西 Yang Xue;Zhang Yu;Bai Xuemei;Zhao Quanxi(Operating Room,Beijing Children's Hospital,Capital Medical University,Beijing 100045,China;不详)

机构地区：[1]首都医科大学附属北京儿童医院手术室,北京市100045

出　　处：《中国病案》2024年第11期9-11,共3页Chinese Medical Record

摘　　要：目的应用信息化技术对手术室护理文书进行管理,为提高手术室护理文书书写质量、护理人员满意度提供参考。方法随机选取2022年1月1日-2023年2月28日某儿童专科医院未进行信息化管理的三级以上手术护理文书200份为对照组,2023年3月1日-2023年12月31日进行信息化管理的三级以上手术护理文书200份为观察组,比较两组护理文书书写质量、缺陷情况、护理人员对信息化管理的满意度。结果观察组护理文书书写质量总分(92.21±7.16)分,高于对照组(86.27±5.28)分,差异具有统计学意义(P<0.05);观察组护理文书缺陷发生率为1.50%低于对照组7.00%(P<0.05)。信息化管理实施后护理人员对护理文书应用的满意度为100%,高于实施前的75.00%,差异具有统计学意义(P<0.05)结论信息化管理可提高手术室护理文书书写质量,提高护理人员对护理文书的应用满意度。Objectives This study aims to apply information technology to manage nursing documents in operating room to provide a reference for improving the quality of nursing document writing in operating rooms and the satisfaction of nursing staff.Methods 200 surgical nursing documents of level 3 or above in a children's specialist hospital without information management from January 1,2022 to February 28,2023 were randomly selected as the control group,and 200 surgical nursing documents of level 3 or above with information management from March 1,2023 to December 31,2023 were randomly selected as the observation group.The writing quality,defects and nursing staff's satisfaction with information management of nursing documents were compared between the two groups.Results The total score of nursing document writing quality in the observation group(92.21±7.16)was higher than that in the control group(86.27±5.28),and the difference was statistically significant(P<0.05).The incidence of nursing document defects in the observation group was 1.50%,which was lower than 7.00%in the control group(P<0.05).After the implementation of information management,the nursing staff's satisfaction with the application of nursing documents was 100%,which was higher than 75.00%before implementation,and the difference was statistically significant(P<0.05).Conclusions Information management can improve the quality of nursing document writing in operating rooms and increase nursing staff's satisfaction with the use of nursing documents.

关 键 词：信息化管理 手术室 护理文书 应用效果 

分 类 号：R47[医药卫生—护理学]