摘要
护理文件书写是医院质量管理的重要内容,同时在医院等级评审中也要求较高。原手工书写方式下医护书写工作量较大,同时差错率较高。该院自2003年相继实施护理电子病历以来,各项模块运行良好,充分体现了电子病历书写方便、快捷、明了、经济、实用、规范、时效性强、可在线保存、随时查阅等优点,使得对护理质量的控制从终末控制变为全过程质量控制,有效地提高护理文件书写质量,减少了文本抄写工作量,以使护士更多地回到患者身边。
Nursing record was an important content of quality management in hospital, and was important in the hospital grade appraisal. It took nurses much time to write nursing record and there were many mistakes in it. Since 2003, we applied electric record and every module run well. Writing electric record was convemence, quick, clear, economic, practical, time-validity, and standardized. Electric nursing record could save on line, check at any time, and managed in all process. Applying electric nursing record improved the quality of nursing record, reduced the worktoad, and let nurses have more time staying with patients.
出处
《中国护理管理》
2008年第9期61-62,共2页
Chinese Nursing Management
关键词
护理文件
电子病历
质量管理
nursing record, electric record, quality management
